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Knowledge and skills for chief nurse executives : a survey of practitioners Donaldson, Sheetal 1993

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KNOWLEDGE AND SKILLS FOR CHIEF NURSE EXECUTIVES:A SURVEY OF PRACTITIONERSBYSHEETAL DONALDSONB.S.N., The University of British Columbia, 1982A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Science inNursinginThe Faculty of Graduate Studies(School of Nursing)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAAugust 1993©  Sheetal Donaldson, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.Department of  /Vcii-S‘t-yThe University of British ColumbiaVancouver, CanadaDate Atf-es ,^ _(Signature) DE-6 (2/88)ABSTRACTSince the late 1800s the role of the chief nurse executive (CNE) has evolved inresponse to changes within both health care and nursing. Whereas, historically, theresponsibilities were diverse (clinical,supervisory and teaching) now they are focused inadministration. Generally, the educational preparation of CNEs has also changed toreflect the role. The most recent study which examined the knowledge, skills andeducation of CNEs was conducted by Sorrentino in 1992. Moreover, the most recentCanadian study to examine these issues was the Canadian Health Administrators Survey(CHAS) (Hastings, Mindell, Brown, & Barnsley, 1981). More recently, nurse leadersnoting dramatic changes within health care and nursing, have suggested that the CNEmay require a new complement of knowledge and skills in order to face the challengesand exploit the opportunities. The education of prospective CNEs should therefore be re-evaluated.The purpose of this study was to survey CNEs of selected acute care hospitalsin British Columbia (100 beds or more) to determine the following: the knowledge andskills perceived to be important to the role in the present and future; the time spent usingspecific knowledge and skills; and recommendations regarding formal educationalpreparation for future CNEs. Data were gathered by means of a mailed questionnaire,adapted from two previous studies, the Ontario Health Administrators Survey (Hastings,1976) and the CHAS (Hastings et al. 1981). The questionnaire listed 48 primary KSswhich were combined into seven knowledge/skill groups (KSGs). The KSGs includedCommunication Skills, Social Science Skills, Management Functions, Knowledge of theOrganization, Nursing Knowledge, Analytical Methods and Skills, and Health ServicesKnowledge. A section on time demand and course recommendations was also included.ii111Questionnaires were mailed to 41 acute care hospitals and 20 usable responseswere received. A mean score was calculated for each KS, KSG and courserecommendation and they were then ranked accordingly. The mean percentage timedemand was also calculated for each KSG. The data were analysed within the managerialclassification scheme as proposed by Katz (1974).The major findings of the study include the following. The CNEs workedin hospitals ranging in size from 100 to more than 400 beds. Most held a masters degree,were responsible for nursing as well as other patient care areas and were in their mid tolate 40s. All were women and a significant proportion had extensive administrativeexperience.Communication skills had ranked highly in the earlier studies andcontinued to do so for the present and future in this study. They also ranked highly intime demand indicating that they have played and will continue to play a significant rolein the CNE position. Several middle management skills, termed technical skills in Katz'sclassification scheme, were also seen as critical to the role, figured prominently in theeducational recommendations and were allocated a large proportion of time. Theseincluded problem-solving and decision making methods, budget preparation and analysis,and management theories and methods. Within this group of skills, evaluation andplanning methods and computers increased in rank in terms of future needs whilepersonnel administration and labour relations were seen as less important. Managingchange within the organization was very highly ranked as a need for both the present andthe future. The CNEs saw specific knowledge areas as important and felt they should beformally taught. These included knowledge of general acute hospitals, ambulatory careprograms and regional services, government health policy, and health services policy andivplanning issues. Although the CNEs appeared to understand the provincial context ofhealth care and the forces which have an impact on it, knowledge of the Canadian healthcare system or of international health care trends was not deemed important to the role.Generally, the need for nursing knowledge per se was ranked low in the present and evenlower in the future in comparison with the other KSGs as it was in the courserecommendations and time demand. However, the KSs, nursing theories and issues andtrends in nursing, were ranked of moderate importance.TABLE OF CONTENTSAbstract^ iiTable of ContentsList of Tables viiAcknowledgements^ viiiChapter One: Introduction^ 1Problem Statement 2Statement of Purpose 2Conceptual Framework^ 2Technical Skill 3Human Skill 3Conceptual Skill^ 3Assumptions^ 4Limitations 4Significance of the Study^ 5Organization of the Thesis 5Chapter Two: Literature Review^ 7Historical Evolution of the Role and Education of the CNE^ 7Empirical Literature on the Role and Education of the CNE(1974-1989)^ 13Key Studies in the Health Management Literature^ 20Current Role Expectations of the CNE and Proposalsfor Graduate Education^ 22Summary^ 26Chapter Three: Methods 28Research Design 28Subjects^ 28Definition of Terms^ 28Instrument 29Data Collection Procedures 32Data Analysis^ 32Ethical Considerations^ 32Chapter Four: Presentation and Discussion of Findings^ 34Response^ 34Demographic Information^ 34Hospital Size 34Position Title 35Educational Preparation^ 36Age and Gender of CNEs 38Number of Years in Present Position^ 39Number of Years in Nursing Administration 40Current and Future Knowledge and Skills 41Comparison with the CHAS Study: 1981 vs 1993^ 53Time Demand^ 54Course Suggestions 58Summary 61viChapter Five: Summary, Conclusions, Implications^ 63Summary^ 63Conclusions 66Implications 67References^ 74Appendices 79Appendix A: Assessment of Knowledge/Skills Required by Chief Nurse Executves^79Appendix B: Covering Letter^ 85Appendix C: Ontario Health Administrators Survey Questionnaire^87Appendix D: Canadian Health Administrators Survey Questionnaire 92Appendix E: Current Knowledge/Skills Raw Scores^ 97Appendix F: Future Knowledge/Skills Raw Scores 100Appendix G: Courses and Corresponding Disciplines 103LIST OF TABLESNumber^ Title Page1 Size of Responding Hospital Sample in Comparisonwith Total Population 352 Titles and Areas of Responsibility of the CNEs 363 Educational Preparation of CNEs 374 Age Range of CNEs 395 Tenure in Present Position 406 Years in Nursing Administration 417 Rank Order of Importanceof Current and Future Knowledge/Skills 438 Comparison of the Top Ten Knowledge/Skillsof the CHAS Study and the Current Study 559 Knowledge and Skill Time Demand 5610 Ranking of Selected Courses from the Disciplines of Nursing,Commerce, and Health Administration 59Viivi iiACKNOWLEDGEMENTSI would like to acknowledge the work of Drs. Marilyn Willman and Sonia Acorn who,as members of my thesis committee, provided the guidance, criticsm, and encouragementneeded to complete this project. I would also like to extend a special thank-you to Dr.Willman for her interest in, and support of the project, as well as providing me withtimely feedback.I would further like to acknowledge my partner Bruce Donaldson and my mother ShaltaVarma for their continued support and encouragement enabling me to complete thisproject.Finally, I would like to dedicate this thesis to my son Kieran Donaldson who, at theage of three, has tried hard to understand why his mother spent so many hoursworking on a thesis.1CHAPTER ONEINTRODUCTIONNurse leaders, noting recent, dramatic developments within health care andnursing, have suggested that the modern chief nurse executive (CNE) may require a newcomplement of knowledge and skills and, if so, the education of prospective CNEs shouldbe re-evaluated. To identify requisite knowledge and skills, it is important to understandthe historical development of the CNE's role and education.Since the late 1800s, the role of the CNE has evolved in response todevelopments within the larger social-political-economic environment, within health care,and within nursing. Whereas the responsibilities, historically, were diverse (supervisory,clinical, and teaching), they are now focused in administration. Educational preparationhas also changed. Few nurse executives in the early 1900s had any post-secondaryeducation aside from a basic nursing education (Erickson, 1980). Now most CNEs inlarger hospitals have at least master's level preparation.Nursing administration as a distinct discipline was first taught at the graduatelevel in 1899, but the discipline did not receive widespread recognition until the 1950s(Carroll, 1989). After a significant decline in the 1960s and 1970s, graduate nursingadministration programs experienced a resurgence and they are now well- established.Exactly how prospective CNEs should be prepared (in nursing or in other disciplines) andwhat they should be taught has historically been controversial.A series of American studies in the 1980s helped clarify the CNE's role, therequisite knowledge and skills, and the optimal education required ( Duffy & Gold, 1980;Freund, 1985; Henry & Moody, 1986; Moore, Biordi, Holm, & McElmurry, 1988;Poulin, 1984b; Price, 1984; Sorrentino, 1992). This information proved useful to2educators planning nursing administration programs. In the 1990s, there are importantdevelopments within health care and within nursing which are expected to affect the roleof the CNE. In order to face the challenges and exploit the opportunities, a newcomplement of knowledge and skills will be required. There has been no study to addressthe issues of knowledge, skills and education of CNEs since that of Sorrentino in 1992.The proposed study, therefore, is an attempt to define, empirically, what the requisiteknowledge and skills of the CNE should be now and in the future.Problem StatementThe Canadian health care system is changing rapidly and dramatically as is therole of the CNE. The education of prospective CNEs must be modified to preparegraduates to function effectively in the modern health care system. However, theknowledge and skills required of the modern CNE and the optimal educationalpreparation have not been adequately addressed by Canadian researchers.Statement of PurposeThe purpose of this study was to survey CNEs of selected acute care hospitalsin British Columbia to determine the knowledge and skills they considered important tothe position, the time they spent using specific knowledge and skills, and theirrecommendations regarding formal educational preparation for future CNEs.Conceptual FrameworkKatz's (1974) classification of managerial skills--conceptual, human and technical--provides an appropriate framework for studying the knowledge and skills needed byCNEs for the following reasons. First, Katz's classification scheme is reflected in theknowledge/skill groupings (KSGs) in the questionnaire. Second, Katz explicates thevarying degrees of importance of specific skills according to the level of management3position. Third, Katz believes that the identification of skills most needed at specificmanagement levels is useful in the selection, training and promotion of executives. Katzdefines the concept of skill as an ability to translate knowledge into action. He believesthat this ability can be developed and is manifest in performance, not merely in potential.Technical SkillTechnical skill implies an understanding of, and proficiency in, a specific kindof activity, particularly one involving methods, processes, procedures or technique. Itinvolves specialized knowledge, analytical ability within that specialty, and facility in theuse of the tools and techniques of the specific discipline (Katz, 1974). At the topexecutive level, the degree of technical expertise required of the administrator isdependent on the size, as well as the technology, of the organization. In smallerorganizations, where the technical expertise may not be as pervasive and seasoned staffassistance not as available, Katz believes that the CNE has a much greater need fortechnical expertise in the specific industry .Human SkillHuman skill is defined as the executive's ability to work effectively as a groupmember and to build cooperative effort within the team s/he leads (Katz, 1974). Katzfurther subdivides human skills into a) leadership ability within the manager's own unit,and b) skill in intergroup relationships. He believes that internal intragroup skills areessential in lower and middle management positions and that intergroup skills becomeincreasingly important in successively higher levels of management .Conceptual Skill Conceptual skill involves the ability to see the organization as a whole. Thisincludes recognizing how the various functions of the organization depend on one another4and how changes in any one part affect all others. It also extends to visualizing therelationship between the particular industry and the broader context, for example, thenursing profession within the broader context of the health care industry and the impactof political, social and economic forces on the health care industry as a whole. Byrecognizing these relationships, the executive should be able to act in a way whichadvances the organization (Katz, 1974). Katz believes that conceptual skill becomesincreasingly critical in senior executive positions where its effects are maximized andmost easily observed. At the top level of administration, conceptual skill becomes themost important ability of all (Katz, 1974).AssumptionsThis study is based on the following assumptions:1. Practicing CNEs are in the best position to describe their role and identify theknowledge and skills they require now and in the future.2. Practicing CNEs are cognizant of trends in the Canadian health care system andwithin nursing and their impact on the role of the CNE.3. To prepare future CNEs effectively, graduate programs in nursing administrationshould reflect practice expectations.4. The CNEs will answer the questionnaire thoughtfully and honestly.LimitationsThe survey population is limited to CNEs employed in acute care BC hospitalswith 100 or more beds and excludes CNEs employed in other areas of Canada and othersettings, thus limiting the generalizability of the findings.Furthermore, by design, the questionnaire responses are closed. Because thereis no provision for clarification or elaboration of either the questions or responses,5important information may be neglected. The questionnaire explicitly divides variablesinto knowledge/skill groups for the purpose of clarity, but this construction may lead toa response bias--for example, rating all of the knowledge/skills within a particularknowledge/skill group high or low based on association rather than independentconsideration.Significance of the StudyThis study will provide a descriptive data base, for British Columbia, of thepracticing CNE's use of time, knowledge/skills, and recommendations for education.Given the changes occurring in the Canadian health care system and their impact on theCNE's role, this study is timely.With few exceptions, the literature on the role of the CNE is American. The onlyCanadian data are from the health management rather than nursing literature and aredated (Hastings et al. 1981). The Canadian and American health care systems are verydifferent and the American literature may not reflect the experience of Canadian CNEs.The proposed study is the first since the Canadian Health Administrators Survey (CHAS)(Hastings et al. 1981), conducted almost twenty years ago, to examine the CNE'sutilization of knowledge and skills and required educational preparation from a Canadiannursing perspective.The results of this study will be useful to nursing organizations such as theRegistered Nurses Association and Nurse Administrators Association of British Columbia,to educators responsible for developing and delivering graduate and continuing educationprograms, to practising and prospective CNEs, and to chief executive officers (CEOs).Organization of the ThesisThe thesis is organized into five chapters. Chapter One reviews the context of the6problem, identifies the purpose and significance of the study, describes the conceptualframework, and presents the assumptions and limitations. Chapter Two presents a reviewof the relevant literature. Chapter Three outlines the research methods and procedures.The findings and discussion are presented in Chapter Four. Finally, Chapter Fivepresents the summary, conclusions, and implications.7CHAPTER TWOLITERATURE REVIEWThe literature review is divided into four sections: historical evolution of the roleand education of the CNE; the empirical literature (1974 to 1989); key studies in thehealth management literature; and current role expectations of the CNE with proposalsfor graduate education in nursing administration.Historical Evolution of the Role and Education of the Chief Nurse ExecutiveIn the late 1800s and early 1900s, the American literature indicates that CNE haddiverse responsibilities including hospital operations management, directing the nursingdepartment, the supervision of clinical activities, and the provision of direct nursing careto seriously ill patients (Erickson, 1980). Many hospitals had associated nursing schoolswhich were staffed largely by students. In such cases, the CNE served also as theschool's director and was responsible for the students' global supervision and clinicaleducation. Many CNEs were ill-prepared for their roles. Most were trained by physicianson an informal basis and the emphasis in instruction was on medical science (Lancaster,1986; Simms, 1989). It was not until 1899, at Teacher's College, Columbia University,that the first program was developed to expressly prepare CNEs for hospital and nursingschool administration (Simms, 1989). Other similar programs were gradually introduced.Still, the majority of CNEs received little formal education beyond a basic nursingprogram. In fact, even by the late 1920s, 25% of CNEs had not attended high school(Burgess, 1928).Three American surveys of CNEs in the 1920s (Burgess, 1928; Goldmark, 1923;National League of Nursing Education, 1927) reported that CNEs felt overwhelmed bytheir many conflicting responsibilities and that overworked nurse executives typically8neglected their teaching duties to concentrate on administration and patient care. Manyof the CNEs suggested that reform was required, although most had not expressed theirconcerns even to their own hospital governing boards.Two events, the 1930s depression followed by World War II, forced theAmerican health care system to change dramatically resulting in a more focused role forthe CNE (Erickson, 1980). During the Great Depression, the health care economic sectorcontracted, there was a surplus of nurses, and many nursing schools closed. FollowingWorld War II, however, demand for health services grew rapidly as a result of thereturning casualties, a new medical sophistication, and an invigorated economy. Therewere insufficient graduate nurses to meet the demand and, in response, more studentnurses were trained and large hospital auxiliary staffs were recruited (Erickson, 1980).The more demanding, complex health care environment required more specializedskills of its participants, including nurse executives. Whereas others assumedresponsibility for hospital and nursing school administration, teaching, and direct patientcare, the CNE remained in charge of nursing administration and the global supervisionof clinical activities (Burgess, 1928; Erickson, 1980).The nursing education establishment recognized that the CNE's role had changedand that new educational initiatives were called for. The Kellogg Foundation played aseminal role in this process through a project designed to conceptualize the role andresponsibilities of the CNE and develop an appropriate graduate level curriculum to trainfuture CNEs (Finer 1952). The project continued for ten years and has left a lastingimpact on nursing administration. On behalf of the Foundation, Finer (1952) and a groupof nurse leaders explored and conceptualized the work of the CNE. They concluded thatthe CNE's work was similar to that of executives in other fields, but "qualitatively"9different. He cautioned;It would be [unwise] to proceed upon the assumption that thegeneralizations [from other fields] can be bodily transferred withoutbeing qualified by the peculiar spirit and human elements involved in thenursing department. What is urgently needed is a marriage, on equalterms, between the science of administration, as it is already known inother fields, and what is and can be known of this science from directcontemplation of nursing service (p. 143).On the basis of this understanding, the Foundation's committee proposed severalobjectives for graduate students in nursing administration: to develop an understandingof administration theory, communication techniques, and trends in health care andnursing; to use nursing research effectively; to develop the ability to appraise nursingcare objectively; to use human resources efficiently and to promote leadership capabilitiesin workers and, finally, to formulate a philosophy of nursing service (Carroll, 1989).With the Foundation's financial support and guided by their objectives, 14 Americanuniversities introduced new graduate level programs in nursing administration (Erickson,1980; Finer, 1952; Mullane, 1959; Simms, 1989).Through the 1950s and 1960s, additional graduate programs developed and theproportion of CNEs with advanced degrees increased. Findings of two American surveysof CNEs from large hospitals (over 200 beds) (Aydelotte, 1968; Erickson, 1970)illustrate this trend. A large proportion of CNEs surveyed held master's degrees (40%and 57%, respectively). Few held doctoral degrees (2% and 7%, respectively) and mostof the remainder held baccalaureate degrees.The education and responsibilities of CNEs in small American hospitals wereclearly different from those of CNEs in large hospitals. For example, a survey of 69CNEs from hospitals of less than 200 beds found that only 25% held a master's degreeand 18% held a baccalaureate degree; most of the remainder held the RN diploma only10(Chapman,1968). Although all of the CNEs surveyed had some administrative duties (thepreparation of staff rosters, for example), the duties were of a less sophisticated nature(only 12% submitted a budget). On the other hand, their clinical duties were substantial(96% regularly made clinical rounds; most participated in direct patient care), and manywere responsible for a variety of non-nursing tasks such as pharmacy, admissions andhousekeeping.In contrast, studies carried out in the 1960s and 1970s established that the workof the CNE in large American hospitals (over 200 beds) was primarily administrative(Aydelotte,1968; Erickson,1970; Hagen & Wolff,1961). Responsibilities within thenursing department included personnel management and the development and enforcementof policies and standards of care. Roughly half prepared budgets, few participated innursing research, and none supervised patient care directly. Although the CNE wasresponsible for liaison with other departments, the role of the CNE in hospitaladministration, as opposed to nursing administration, was limited. For example, Hagen& Wolff (1961) noted that, of the 15 CNEs they studied, none was involved in theutilization of non-nursing personnel, equipment or space, and few were involved in long-range planning.Although it was clear that CNEs required more sophisticated administrative skills,prospective graduates were unlikely to acquire these skills in nursing administrationgraduate programs because these programs were in relative decline from the mid-1960s(Cleland, 1984; Price, 1984; Thomlinson, 1991; Wagner, Henry, Giovinco & Blanks,1988). For example, although the absolute number of nurses in administration programsremained fairly stable from 1964 to 1973, the proportion of graduates in theadministration stream, as opposed to education or clinical specialization, fell from 17%11to 7% over the same interval (Stevens, 1977).Cleland (1984) cites three interrelated reasons for the decline of nursingadministration programs. First, new nursing conceptual frameworks did not emphasizeadministration; second, the job market was unfavourable for administration graduates;and third, few educators within nursing faculties were qualified to teach administration.The concept of nursing as a profession required that nursing develop conceptualframeworks and a unique body of knowledge. This task fell to nurse educators primarilyand therefore they were in demand. Clinical nurse specialists who served as expertresource persons within an increasingly sophisticated medical and nursing environmentwere also in demand (Cleland, 1984; Mckay, 1971; Price, 1984). In comparison, thejob market for administration graduates was less favourable. For example, many hospitalsstill promoted nurses from within their organizations to administrative positions ratherthan hiring new graduates of nursing administration programs (Cleland, 1984). Fewfaculty were qualified to teach administrative subjects and some nurses interested inadministration sought graduate preparation in other disciplines such as business, healthor public administration (Cleland, 1984; Poulin, 1984a; Stevens, 1977; Thomlinson,1991).By the mid-1970s, the number of academically-prepared CNEs in large hospitals(over 200 beds) had declined significantly. Fewer than 20% held a master's degree(Stevens, 1977) and, similar to the American figures previously noted, many CanadianCNEs from small hospitals had little formal education; 67% having no preparationbeyond the basic program ( Leatt, 1985). Nurse leaders recognized that not only wasthere a real demand for nurse administrators well-prepared at the graduate level, but alsothat the nursing profession's autonomy and development were threatened by this lack of12administrative presence. This was true both in education, where more nurses might trainin other disciplines, and in the hospitals, where non-nurses might direct nursing services,( Jordan, 1979). As a result, graduate programs in nursing responded with a rapidincrease in the number of nursing administration majors. From the 1970s to 1982, thenumber of programs doubled and, in 1985, there were at least 65 graduate programs innursing administration in the United States (Wagner et al. 1988). Some programs wereof questionable quality because they had developed too fast with too few resources,especially qualified faculty (Cleland, 1984; Poulin, 1984a; Simms, 1988; Stevens, 1977).A more pervasive problem, however, was a lack of consensus amongst educatorsas to what nurse administrators should be taught, which resulted in marked variability inprogram content. At the core of the debate was the struggle to define nursing generallyand the CNE's role in particular. Educators disagreed as to the nature of the knowledgeCNEs should possess; whether "...broad, general and conceptual or intense, specific andrequiring actual clinical practice" (Poulin, 1979, p. 47). The need for clinical specialtyknowledge was especially contested. Erickson (1970) argued that it was not needed whileothers felt that it was and suggested that the CNE with such knowledge was in a betterposition to keep abreast of developments in health care, manage clinical staff, andunderstand patient needs and expectations (Arndt & Huckabay, 1980; Germain, 1970).It is not surprising, therefore, that graduate curricula varied considerably amongprograms.Notably absent from the discussion, was objective evidence of what CNEs neededto know to practice. Schlotfeldt (1974) held educators responsible for this lapse. Theeducators, she claimed, had been unduly concerned with the educational process itself--teaching strategies, student evaluation and curriculum structure--and less concerned with13the critical evaluation of outcomes--whether their graduates were competent to practice.She called, therefore, for a formal delineation of the competencies that graduates requiredto practice effectively, and educators sympathetic to this suggestion proposed a moreempirical approach to curriculum development. A series of American studies weretherefore initiated to identify the knowledge and skills required of the practicing CNE andto determine if graduate administration programs prepared their graduates effectively.Empirical Literature on the Role and Education of the CNE (1974 to 1989)The literature will be presented as follows: studies of the role of the CNE; studiesof the effectiveness of graduate programs; and a synthesis of the major findings.Poulin (1984b) interviewed 12 leading CNEs of American hospitals, recognizedas especially competent or progressive by their peers, to examine the role of the CNEand the conditions affecting performance. Several duties consistently identified asimportant were developing policies, budgeting, facilitating participatory management,implementing staff education programs, expanding their span of control, and coordinatingprograms with other health care agencies. The CNEs reported that the most commonbarriers to their effectiveness were those that resulted from cost constraints andorganizational policy.In an attempt to define the knowledge and skills required by CNEs, Freund(1985) examined the question from the perspectives of the CNE, and the employer, thehospital CEO. CNEs and CEOs with 250 university-affiliated hospitals were asked whatmakes CNEs effective. The responses of the 172 CNEs and 126 CEOs who completedthe survey were sorted into seven knowledge/skill categories and ranked according tocategorical frequency. On this basis, the investigators were able to compare the CNEs'and CEOs' responses. The CNEs' responses in descending order were as follows: general14management /health /nursing knowledge, human management skills, total organizationalview, CEO support, medical staff relations, flexibility/negotiation/compromise, and"political savvy." The top three categories were the same for CEOs and CNEs; however,CEOs mentioned certain skills more often (medical staff relations) and others less often(CEO support, CNE political savvy) than did the CNEs.In a related study, Moore et al. (1988) surveyed CNEs and CEOs of 500randomly selected American community hospitals with 100 to 400 beds. The studyparticipants were provided with a list of the seven characteristics of CNEs' effectivenessas described by Freund (1985) and asked to rank them in order of importance. The 291CNEs who responded ranked the categories (in descending order) as follows: humanmanagement skills, CEO's support, management /health /nursing knowledge, totalorganizational view, flexibility /negotiation /compromise, political savvy and medicalstaff relations. The categorical ranks provided by the 171 CEOs who responded weresimilar, the only significant difference being that CEOs felt their support for the CNEwas less important for the latter's success than did the CNEs. Of the 147 respondentswho added comments, 39% of CNEs and 27% of CEOs indicated financial managementand business skills were essential for the effective CNE.Although the two studies cited above (Freund, 1985; Moore et al. 1988) aresuperficially similar, there are important differences in the samples (university-affiliatedversus community-based administrators) and design (retrospective versus prospective).Because of these differences, results of the two studies are not strictly comparable.Nonetheless, findings are similar and suggest similar conclusions. First, three categories--management/health/nursing knowledge, human management skill and total organizationalview--were highly ranked by CNEs in both studies. These observations, combined with15the comments about fiscal skills, suggest that the core knowledge/skills of the effectiveCNE are in the area of management, administration (with some fiscal ability), andnursing knowledge. Second, in both studies the CEOs consistently perceived differentcharacteristics as important. In general, compared to their CEOs, CNEs "over-valued"certain skills (political savvy; CEO support) and "under-valued" others (totalorganizational view; medical staff relations). Freund concluded that CNEs were simplymore aware of the political challenges of their position. On the other hand, Moore et al.suggested that the CNEs may have conceived of their role as narrower than the moreglobal role expected of them by their CEOs. Unfortunately, these studies are not asuseful as they might be because Freund's knowledge/skill categories appear arbitrary; noconceptual framework or logic is evident. The first category in particular is over-inclusive and obscures the relative importance of management versus nursing knowledge.In a later study, Sorrentino (1992) had a purpose similar to that of Moore et al.(1988), but with an added dimension. She sought to define not only what knowledge andskills CNEs possessed, but also what they should ideally possess. In addition, she hopedto obtain more useful information than the earlier investigators by re-defining theknowledge/skill categories in a more logical manner. To do this, both CNEs and theirCEOs were surveyed and asked to record actual and ideal CNE competencies in 14,newly defined, knowledge/skill categories. Administrators from all 213 Florida hospitalswere sent the questionnaire. Of the 84 CNEs who responded, 82% held a master'sdegree. Only 30 CEOs replied. Both CNEs and CEOs cited the same knowledge andskills as important to the practicing CNE: leadership, interdepartmental communication,budgeting, and conflict resolution. From the CEOs' perspective, the greatestdiscrepancies between the actual and the ideal CNE competencies were in the following16categories: strategic planning, managing change, and resource allocation. From theCNEs' perspective, however, the greatest differences were in the following:communication, health care delivery systems, development and implementation of nursingmodels, budgeting, accounting, and finance. In general, CEOs were more critical of theCNEs than the CNEs were of themselves. The author concluded that there was ahierarchy of CNE knowledge/skills apparent to both CNEs and CEOs and that there wasroom for even this well-educated sample of CNEs to improve. Furthermore, in aconclusion similar to that of Moore et al. (1988), she noted that CEOs may expect moreof the CNEs than the CNEs do of themselves, both in terms of overall performance andparticular skills, especially administration and strategic planning, and in terms of theirrole (i.e., greater participation in hospital administration).In order to determine what knowledge and skills were required of CNEs fromsmall (under 100 beds) rural hospitals, Henry and Moody (1986) studied a sample of 10"exemplary" and relatively well-educated CNEs. Two held master's degrees and five heldbaccalaureate degrees. The investigators both interviewed and observed their subjects atwork and interviewed the CNEs' co-workers. The investigators, who acknowledged theobvious limitations of their study (small, selected sample; highly subjective analysis),found that the effective CNEs consistently displayed certain abilities. These includedmanagement skills (especially staff recruitment and retention, and staff motivation),public relations skills (especially the ability to maintain a public profile and buildnetworks), and the ability to establish productive medical staff relations. A considerableamount of the rural CNE's time was spent in direct patient care. Co-workers reportedthat effective CNEs were intelligent, practical and versatile. However, even these"exemplary" CNEs felt poorly prepared to deal with the political and fiscal aspects of17their positions.Other American investigators have attempted to define the optimal education forprospective CNEs and to determine how effective graduate programs have been inproviding this education. The issues were examined from the perspectives of threegroups: experienced CNEs, recent graduates, and employers of the latter.To determine if a single graduate program in nursing administration (Iowa StateUniversity) was effective, three educators from that program surveyed its recentgraduates to establish whether or not the graduates were professionally successful andsatisfied (Thomas, Erickson, & Heick, 1974). Of the 71 respondents, many of whom hadmilitary affiliations, the large majority (96%) were employed and most of these heldsenior positions in administration or education. Most (64%) reported that their positionswere challenging and that they had good to excellent opportunities to develop their skillsin administration or education. The majority participated in research to some degree andhad the opportunity to improve their research skills. In addition, most graduates feltfuture career prospects were promising. For example, 63% saw themselves as CNEswithin ten years. The investigators concluded that the graduate program was effective onthe basis of the success of its graduates. Unfortunately, because of the exclusive use ofself-evaluation and the selective sample, the results of the study cannot be generalized toother programs and graduates.In an effort to determine what graduate level administrative preparation was moreappropriate for CNEs, Duffy and Gold (1980) surveyed two groups of CNEs withnursing degrees (43) and business degrees (33). Respondents rated their preparedness for23 managerial skills using an ordinal scale from 1 to 7 (no preparation to excellentpreparation). In addition, they were encouraged to make additional comments as18necessary. Both nursing and business graduates perceived their aggregate preparation asadequate and the mean score for each group (4.0) was identical. Furthermore, bothgroups reported similar scores for 18 of the 23 managerial skills considered individually.The two groups did differ in certain aspects. Compared to the business graduates, thenursing graduates felt better prepared in the following: nursing content, nursing and in-service education, and research skills; but felt less well prepared in budgeting, marketing,and statistics. A review of the respondents' comments supported the conclusion that,although nurse graduates recognized the importance of fiscal matters, they were ill-prepared to handle them. In fact, several suggested the nursing graduate program shouldinclude courses in business. The nursing graduates also perceived a need to developgreater political finesse and to expand their role within the organization.To determine what type of graduate nursing program best prepared nurseadministrators, Price (1984) surveyed graduates and their employers. Graduates hadcompleted one of three program formats: nursing service administration with someclinical component (five programs); nursing administration with no clinical component(two programs); and clinical programs with an administrative component (threeprograms). The 141 graduates were asked to rate the effectiveness of their programs inpreparing them for specific responsibilities and the 92 employers were asked to rate theperformance of the graduates. Both were asked to identify the core competencies of thenurse administrator and to comment on the graduate program content. All the graduatesand their employers identified administrative and management training as the mostimportant aspect of a graduate program in nursing administration. Although the majorityof graduates and their employers reported that the graduate programs had providedadequate preparation, all identified a need for more intensive business training, especially19fiscal. To obtain the additional content, most agreed that the prospective CNE should beeducated in a graduate program in nursing administration, but with a liberal exposure tocourses in other disciplines such as business and health administration.What can be concluded from these attempts to empirically define the CNE's roleand responsibilities and the optimal educational preparation? Admittedly, the literatureis neither comprehensive nor flawless. Nonetheless, certain themes emerge. First, theCNE's was an administrative role and the most important task was personnelmanagement. To a lesser degree, the CNE was responsible for planning and coordinatingprograms and services and developing and implementing policy. Second, CNEs wereincreasingly expected to prepare budgets and participate in fiscal planning although theyfelt relatively unprepared for these responsibilities. Third, although the CNEs requirednursing knowledge, most were not involved in direct nursing care and did not requireclinical specialization. Furthermore, few had substantial research or teachingresponsibilities.The above view of the CNE's role was supported by the findings of studies ofeducational preparation. The most successful programs were those with some nursingcontent that most comprehensively and directly prepared graduates for administrativeroles. Although the majority of graduates and their employers felt the graduate programin nursing provided adequate preparation, they identified a need for more extensive fiscaltraining. It was felt that CNEs should be educated in a program of nursing administrationbut that exposure to faculty from other disciplines--business and health administration andpublic health--would be useful. In order for the CNE to assume an expandedadministrative role within the organization, both CNEs and CEOs felt that moresophisticated administrative and political skills were required.20Key Studies in the Health Management LiteratureBecause of the limited number of nursing studies examining the knowledge andskill requirements of CNEs, the health management literature was also reviewed. TwoCanadian studies are important because they provide the format for the current study andone offers insight into the role of the CNE.The 1976 Ontario Health Administrators Survey (OHAS, Appendix C) and the1978 Canadian Health Administrators Survey (CHAS, Appendix D) were conducted insequence and with a similar purpose by Hastings ( Hastings, 1976; Hastings et al. 1981).Their intent was to study health administrators from all health care sectors, firstprovincially, then nationally, in order to collect demographic, professional andeducational needs data which could be used to plan educational programs for healthadministrators.The OHAS survey included CNEs although the number who responded is notrecorded and the responses were not analyzed separately from those of otheradministrators. Therefore, although the study represents a crucial step in the developmentand validation of the questionnaire used in the CHAS study and modified for the currentstudy, the OHAS survey does not provide insight into the role of the CNE in Ontario.In this regard, the CHAS is more useful and will be discussed in greater detail.The CHAS investigators surveyed 5,883 senior health administrators, includingnurses, in all health sectors. Health executives were questioned with respect todemographic data, the perceived importance of defined knowledge and skills at that timeand in the future, time spent using defined communication skills, and what continuingeducation format and content they considered desirable. A total of 4074 (69.3%)administrators completed the questionnaire. The 408 CNEs who responded worked in a21variety of settings including teaching hospitals (52); large hospitals (69); small hospitals(221); and public health services (66). A large hospital was defined as having more than200 beds. For each of the practice settings, the CNE median age was 45-50 years. TheCNEs had occupied their positions for a median of five years and many had held thesame position for ten years-40% of those in teaching hospitals and 30% of those in non-teaching hospitals. Forty-five percent of CNEs held only a diploma or BSNqualifications; however, 33% had completed a one-year health organization andmanagement course and 22% had graduate level preparation in a health administrationfield. The health organization and management course had been completed by 42% ofCNEs in small hospitals and 27% in large hospitals, but by only 8% of those practicingin teaching hospitals. Conversely, 28% of CNEs practicing in teaching hospitals andlarge hospitals had graduate preparation and only 8% of those practicing in smallhospitals had such preparation.From a list of 43 possible knowledge skill areas, CNEs consistently identified thefollowing among the ten most important: problem-solving and decision-making methods;evaluation methods (e.g., of programs or quality of care); communication skills; effectingand managing change; and the law as it relates to health services. Certain skills wereidentified as uniquely important to a particular practice setting. Respondents practicingin large and teaching hospitals identified specific management skills as important:management theories and methods; labour relations and collective bargaining; and person-to-person relations and group dynamics. In contrast, CNEs from smaller hospitalsidentified health promotion skills as particularly important.The CHAS survey had several limitations. Although CNEs were surveyed, noattempt was made to assess the importance of nursing skills specifically and, despite22attempts, no useful information with respect to the time devoted to variousknowledge/skills was obtained. Furthermore, the method of analysis was somewhatlimited. For example, only the top ten skills were listed, therefore, no information isavailable with respect to the rank order of the remaining skills.Current Role Expectations of the CNE and Proposals for Graduate EducationIn the 1990s, health care and nursing in Canada are changing dramatically.These developments are expected to have an impact on the role of the CNE. The newhealth care system is characterized by modern expectations of health care and healthproviders, increasing fiscal restraint, the politicization of health care, new communicationand medical technologies, a shift from acute care to outpatient and ambulatory services,and leaner, decentralized organizational structures (Coyte, 1990; Lancaster, 1986;Manga, 1992; Poulin, 1984b; Roch, 1992; Seaton, Evans, Ford, Fyke, Sinclair, &Webber, 1991; Simms, 1988; Sovie, 1987; Styles, 1988; Taylor, 1989).Three trends within nursing, too, directly affect the nursing administrativestructure and the CNE. First is the elimination of middle management positions (directorsand supervisors) for reasons of cost containment and improved bureaucratic efficiency(Sabatino, 1991). Second is the introduction of participatory management strategiesintended to empower nurses and improve their work life and, thereby, improve nurserecruitment and retention (Poulin, 1984a; Sovie, 1987). The third is a trend withinnursing towards greater specialization of roles, both clinical and administrative, therebyrequiring the implementation of structures which facilitate communication, integration,collaboration and co-ordination within the nursing department (Poulin, 1984a).It has been suggested that the role of the CNE must evolve along with the newhealth care system, but also that CNEs have a unique opportunity to participate in23shaping the health care system of the future (Dick, 1992; Manga, 1992; Roch, 1992).The modern CNE may require a new set of knowledge and skills to meet thesechallenges. If so, graduate programs in nursing administration will also be required todemonstrate new initiatives to effectively prepare CNEs. In the modern, complexenvironment, what are the most important qualities, knowledge and skills needed by theCNE?. Many nurse leaders have offered their opinions.Poulin (1984a) asserts that the CNE must be able to communicate, collaboratewith others, coordinate and integrate programs and services, demonstrate flexibility andinterpret the role of nursing to other groups outside of nursing. Sovie (1987) suggests thatstrong leadership is required to manage the increasingly complex and fluid health careenvironment. She adds that an informed CNE is required to empower nurses andrecognize their expertise and enhance their productivity through a culture of sharedownership.The modern CNE must understand new concepts in management. For example,Alexander (1988) suggests that the quality of a nurse's work life and the environment inwhich the nurse practices is likely to influence the nature of nursing outcomes. O'Brien-Pallas and Bauman (1992) have developed a theoretical model which attempts to exploreand establish links between the individual nurse's experience, the institutional context ofwork and the broader health care system. They encourage CNEs to use this model tosystematically evaluate the quality of nurses' work life and to facilitate the achievementof quality outcomes.Advances in information technologies have added to the complexity of nursing.Styles (1988) views this as an asset to be capitalized upon by the CNE. She points out,for example, that sophisticated, automated patient care systems have the potential to free24nurses from some routine tasks and allow them more time for direct patient care. Withinorganizations, the new technology permits a more dynamic, less bureaucratic structure.While this means greater efficiency, personnel job security, especially in the middlemanagement ranks, tends to be compromised (Gilmore, 1990). In addition, the newinformation and medical technologies raise difficult legal and ethical questions, such asissues of patient confidentiality and the appropriate use of scarce resources (Christensen,1991; Milholland & Heller, 1992; Simms, 1988).Because of fiscal restraint, CNEs must make more efficient use of nursingresources (Manga, 1992; O'Brien-Pallas, 1992; Roch, 1992). They must demonstrateappropriate management of nursing manpower, promote efficiency and cost-effectivenessand preserve the quality of care. For example, while a substitution of nurses in onecategory for those in another may appear cost-effective, potential drawbacks may includea decrease in productivity, competence, quality of care, nursing knowledge and anincreased risk to patients (Manga, 1992). O'Brien-Pallas (1992) argues that CNEs mustunderstand case costing principles and approaches and their implications for nursingpractice. Huber, Delaney, Crossley, Mehnert and Ellerbe (1992) concur and argue that,while the models developed to explain the variations of nursing costs within a case mixgrouping are a good start, more formal nurse manpower accounting is necessary. Sovie(1987) and Halloran (1985) suggest that clinical outcomes must be critically evaluated andthat this process requires an accurate measurement of the quality of care and thedevelopment of nursing indices.The politicization of health care in Canada has placed an increasing emphasis onthe political aspects of the CNE's role. Taylor (1989) identifies two skills of particularimportance: information processing and networking. She suggests that information must25be processed continually to identify future threats and opportunities, set politicalobjectives and engage in proactive strategic planning to ensure organizational survival andgrowth. Networking at the government level is necessary to exert influence on fundingand policy issues affecting the health care system generally and nursing specifically.Biordi (1986) suggests that female CNEs must examine their role from a feministperspective, increasingly subscribe to the public and political nature of their role, enlargetheir professional networks, and develop mentor networks. Vance (1982) also supportsthe potential importance of mentor networks.Several educators have suggested that the education of prospective CNEs shouldchange in order to better prepare the graduate to function effectively and, in some cases,their proposals for new programs have already been implemented. In 1985, a jointcommittee of the American Association of the Colleges of Nursing and the AmericanAssociation of Nurse Executives suggested that the content of a nursing administrationgraduate program should include business core and management cognates, advancednursing core including research, issues, roles, and theory; synthesizing core in nursingadministration, and a concentrated residency or practicum experience (Fralic, 1987).Some administrators have suggested the inclusion of specific courses such as healtheconomics, marketing, cost accounting; health policy and planning; public relations;research; computer and information technology; ethics; and health law (Fralic, 1988;Lancaster, 1986; Simms, 1988). Cleland (1984) developed and implemented a one-year,post-master's program in executive-level administration to follow a clinical specializationprogram. The majority of courses were taught by faculty in business administration.Thomlinson (1991) has reported the course content of a program offered at the Universityof Manitoba. Most courses were offered in the nursing program, but a significant26proportion of the program consisted of electives from the areas of business, managementand public health. The suggested electives included the following: marketing, industrialrelations, human resource management, organizational decision making, and public policyand planning Carroll (1992) describes the introduction of a dual-degree program atDuquesne University. Graduates complete the requirements for both the master of sciencein nursing and master of business administration programs in a minimum of three yearsof full-time study.SummaryThe role of the CNE has changed significantly over the past 70 years. Educatorsof prospective CNEs must have a clear understanding of the practicing CNE's role andhow it might change in the future. As a result of studies in the 1980s, most investigatorsnow agree that the CNE has a primarily administrative role that requires an array ofknowledge and skills from nursing, management and business disciplines. There issupport from many CEOs for the CNE to assume a larger administrative role providedthat she demonstrates more sophisticated administrative skills, especially fiscal andstrategic planning, and political skills.The modern CNE faces additional challenges posed by developments in healthcare and nursing such as fiscal restraint, new administrative structures, evolvingmanagement concepts, and new technologies. Moreover, the CNE is expected to assumea more political role in order to both function more effectively and promote the interestsof the nursing profession.Amongst educators, there is general agreement that the CNE requires at leastmaster's level preparation, based in the nursing program but including at least someinstruction from other disciplines such as business administration and public health.27There is considerable debate about where the emphasis should be placed and the specificstructure and content of the optimal nursing administration program. Some, but not all,have called for a practicum experience and extra instruction in research, ethics, law andinformation technology.While the empirical literature has provided many answers, some important issueshave not been addressed, such as the proportion of the CNE's time in which particularknowledge and skills are used. Furthermore, there are no current studies in which CNEshave been asked for their perceptions of the future of the role or of an appropriateeducational program for prospective nurse administrators.With few exceptions, the empirical literature is from the United States andbecause of the very different health care systems, the findings may not be directlyapplicable in Canada. Furthermore, many of the studies are retrospective and highlysubjective and use tools that are inadequate (e.g., lists of knowledge/skills that arearbitrary and incomplete). The available Canadian data are from the health managementliterature and are dated ( Hastings et al. 1981).Given the rapid and dramatic changes occurring in the Canadian health caresystem it is time to re-examine the role of the CNE. This study examines, from aprovincial perspective, knowledge and skill requirements of the CNE's role as well aseducational preparation for the position. The findings of this study will prove useful toprofessional nursing organizations, educators preparing future nurse administrators, andpracticing CNEs and CEOs.28CHAPTER THREEMETHODSThis chapter describes the methods and procedures utilized to conduct the study.The research design, sample selection, instrument, data collection procedures and dataanalysis are outlined.Research DesignThe study was a descriptive survey. Four areas were examined: (a) selecteddemographic features of CNEs in B.C.; (b) the perceived importance of definedknowledge/skills for successful performance in their jobs now and in the future; (c) anassessment of the time spent using each knowledge/skill; and (d) their recommendationsfor the educational preparation of future nurse executives.SubjectsThe survey population was comprised of CNEs who were employed and had theultimate responsibility for the operations of the nursing department in the 41 BritishColumbia acute care hospitals with 100 or more beds, as identified in the 1991 CanadianHospitals Directory. CNEs of long-term care, psychiatric or rehabilitation facilities,military hospitals, and Red Cross outposts were excluded.Definition of TermsFor the purposes of this study, the following definitions and abbreviations wereused.Chief Nurse Executive (CNE): The most senior nurse in the organization who hasultimate responsibility for the operations of the department of nursing. She/he could alsohave administrative responsibility for other departments in addition to nursing. Othertitles commonly employed include Vice President Nursing, Assistant Administrator of29Nursing, Chief Nursing Officer, Director of Nursing, Assistant Executive Director ofNursing, Vice President Patient Care Services, and Assistant Executive Director PatientCare.Knowledge and skill (KS): Individual knowledge areas and/or skills identified in thequestionnaire used in the present study.Knowledge/skill grouping (KSG): The groupings of knowledge/skills in thequestionnaire used in this study. They include: management skills; analytical methods andskills; health services knowledge; knowledge of the organization; communication skills;social science skills; and nursing knowledge .Time Demand (TD): The allocation of time, expressed as percent of total time, usinga particular knowledge/skill or group of knowledge/skills.InstrumentThe survey questionnaire (Appendix A) was adapted from the questionnaireoriginally developed for the Ontario Health Administrators Survey (OHAS, Appendix C)and modified for the Canadian Health Administrators Survey (CHAS, Appendix D).The OHAS questionnaire was first used in 1975 and was originally developedthrough consultation with, and pre-testing by, selected Ontario health administrators ineach of the health sectors surveyed. The questionnaire included a section on demographicdata such as age, gender, tenure, educational preparation, job title,and the size of theinstitution, as well as seven 43 knowledge/skill groups. Because a number of problemswere identified with the OHAS questionnaire, it was revised by the CHAS investigatorsbefore its use in a 1977-1978 survey. In the CHAS version, additional knowledge/skillsareas were added and some questions were re-designed. Contributions to thequestionnaire designed for the CHAS came from members of a National Advisory30Committee (NAC) organized by the study team for the project as well as health officialsin each province. NAC members included representatives of each provincial governmentand the federal government appointed by the Deputy Ministers of Health of the respectivegovernments, and representatives from the Canadian College of Health ServicesExecutives, the Canadian Hospital Association, the Canadian Nurses Association and theCanadian Public Health Association. The revised questionnaire was pre-tested on astratified, random sample of approximately 100 health administrators selected from listsprovided by the NAC members. Final modifications were made in 1977 with the help ofthe NAC, and a four-page questionnaire resulted (Hastings, 1981). In their final report,the CHAS investigators acknowledged that the questions regarding health executives' timeallocations were poorly constructed, and therefore the time demand data were of marginalutility.Because the purpose of the present study is different than that of the CHAS, thestudy population is more narrowly focused, and in order to address the identifiedshortcomings of the CHAS questionnaire, it was necessary to further revise it for thecurrent study. Questions regarding nursing-specific knowledge were added, the contentof which was based on a review of nursing literature on the role and function of theCNE. The time demand section was designed to be consistent with the sections onknowledge/skill importance and educational recommendations. The sections of the CHASstudy dealing with continuing education were not relevant to this study and weretherefore deleted. A new section which determines CNEs' recommendations for formaleducation was added. Twenty post-graduate courses from three administrative disciplines--nursing, health, and business--reflect the content of the seven knowledge/skill groups asidentified above, have been listed for respondents to use in recommending formal31education. Courses included in this section were determined by reviewing coursedescriptions from the above three disciplines, as well as literature on graduate preparationof nurse administrators.Each of the seven knowledge/skill groupings was assigned to one of the threemanagerial skills--technical, human, and conceptual--identified by Katz (1974) and usedas the conceptual framework for this study. Technical skill encompasses theknowledge/skill groupings of management functions (numbers 1-7), analytical methodsand skills (numbers 8-14), and nursing knowledge (numbers 44-48). Human skillcorresponds to the knowledge/skill groupings of communication skills (numbers 36-38),and social science skills (numbers 41-43). Lastly, conceptual skill corresponds to theknowledge/skill groupings of health service knowledge (numbers 15-26), knowledge ofthe organization (numbers 27-35), and social science skills (numbers 39 and 40).To determine the content validity of the revised questionnaire, especially the newand modified sections, it was administered to a group of four senior nurse executivesindependent of the survey population. Based on their feedback, minor revisions weremade. Specifically, to clarify the distinction between KS numbers 44 and 46, number 44was changed from "nursing theory and its application in practice" to "knowledge ofnursing theories and their application in administration and practice." Also, in question8, a statement was added indicating that the total time spent on all KSGs could exceed100%. The questionnaire is used and modified with the express permission of theprincipal investigator of the CHAS study, Dr. John Hastings (personal communication,September 23, 1992).The survey questionnaire identifies 48 primary knowledge skills (KS) which arecombined into seven knowledge/skill groupings (KSG). For each KSG, a score is32calculated based on the mean score of all the knowledge/skills in that KSG for allrespondents. The minimum score possible is 48 while the maximum possible score is240. The rank of the KSGs was determined on the basis of their scores (highest rank withhighest score). The same procedure was followed to rank the KSGs with respect to timedemand and educational recommendations.Data Collection ProceduresThe questionnaire was mailed to the CNEs with a self-addressed, prepaidenvelope and a covering letter (Appendix B) describing the purpose of the study andprocedures for guaranteeing confidentiality. Non-respondents were contacted by telephoneat two and four weeks after the initial mailing date to encourage their participation.Data AnalysisDescriptive statistics were used to analyse the data (frequencies, means andpercentages). The mean was calculated for each of the 48 knowledge/skills (current andfuture) then ranked accordingly. For each KSG the mean was calculated for that groupbased on the mean score of all the knowledge/skills within that group for all respondents.Each KSG was then ranked accordingly. The same procedure was used to rank the 20courses and KSGs time demand.Ethical ConsiderationsPrior to conducting the study, approval of the procedure for protection ofsubjects' rights was obtained from the University of British Columbia BehaviourialSciences Screening Committee for Research and other Studies Involving Human Subjects.A covering letter (Appendix B) was mailed with each questionnaire which explained thepurpose of the study and advising the subjects that consent to participate was indicatedby return of the completed questionnaire. Anonymity of respondents was maintained by33coding participants' names and reporting the data in aggregate form only. All raw datawere destroyed upon completion of the study.34CHAPTER FOURPRESENTATION AND DISCUSSION OF FINDINGSThe findings and discussion are presented as follows: the response rate; thedemographic data; ratings of current importance of knowledge and skills in relation tothe past (the CHAS study) and the future; estimates of time allocation for eachknowledge and skill used; and, finally, the CNEs' suggestions for educationalpreparation.ResponseTwenty-four questionnaires (58.5%), from a total of 41, were returned prior tothe deadline date. Of these 24 questionnaires, four could not be used. In two cases, theposition of CNE was vacant; in the other two, the facility had less than 100 beds (34 and90). Data from the remaining 20 questionnaires were analysed.Demographic InformationRespondents were requested to provide specific information about hospital sizeas well as position title, educational preparation, age and gender, and tenure in currentposition.Hospital SizeThe number of beds is described using increments of 100, with a range of 100to more than 400 for both the study sample (n=20) and the potential population (N=41).As shown in Table 1, most of the hospitals had 100 to 200 beds; five had more than 400beds with a range from 430 to 900. Four were teaching hospitals. The sampledistributions are similar to the population distributions.35Table 1Size of Responding Hospital Sample" in Comparison with Total PopulationbNumber of Beds^Sample^PopulationFrequency Percent^Frequncy Percent100-199^8^40^16^40200-299 4^20^7 17300-399^3^15^8^19> 400 5^25^10^24a n=20, b N=41Position TitleAs shown in Table 2, the position titles were grouped into five categories. Thosetitles which did not exactly match one of the five categories were grouped with theclosest category. For example, both the titles "Director of Patient Services" and "VPServices" were included in the category of "VP Patient Care Services." The mostfrequently used titles were VP Patient Care Services (30%), VP Nursing and Patient Care(20%), and Assistant Executive Director Patient Care Services (20%). The position titlesgenerally reflect the scope of the CNE's responsibility and, in most cases (70%), theCNE has responsiblity not only for the nursing department, but other departments aswell.This finding is similar to that of Poulin (1984), in which the same proportion ofCNEs (70%) also had responsibilities outside of the nursing department. Whereas, inPoulin's study, the CNE's designation often suggested that the responsibilities lay onlywithin nursing (e.g., VP Nursing), the designations of CNEs in the current study appearto acknowledge a broader scope of responsibility (e.g., VP Patient Care Services).36Whether this indicates that the CNEs' non-nursing responsibilities have actually increasedTable 2Titles and Areas of Responsibility of CNEs aTitle Frequency Percent Area of ResponsibilityNursing^Nursingand OthersVP Nursing 3 15 3 0VP Nsg.& Pt.Care 4 20 0 4VP Pt.Care Services 6 30 1 5Asst.Exec.Dir.Pt. 4 20 0 4Care ServicesDirector of Nsg. 3 15 2 1a n=20is not clear, although with the trend to leaner management structures with fewerpersonnel and greater administrative efficiency, it may well be so (Manga, 1992;Roch,1992; Sovie, 1987). Moreover, the new titles may be an indication that the CEOssupport the trend for CNEs to assume a broader administrative role as has been suggestedby Freund (1985), Moore et al. (1988), and Sorrentino (1992). However, exactly whatthe nature and extent of the CNEs' responsibilities are outside the department of nursing,is not clear from these data.Educational Preparation The majority of the respondents (75%) were prepared at the graduate level (Table3). Of the fourteen CNEs holding a masters degree, ten (53%) held degrees in disciplinesother than nursing. Twenty percent of the CNEs held baccalureate degrees in nursing37(BSN) while 11% had a nursing diploma as their highest education level. Only fourindividuals (20%) were pursuing further educational preparation, two the masters degree(both in non-nursing disciplines) and two the health management certificate.Table 3Educational Preparation of CNEs Educational^Frequency Percent^Education inLevel ProgressDiploma^2^11^Manag. Cert.(1)BSN^4 20^MHA;Masters inOrganizationLeadership (2)Other^0^0BachelorsMSN^4^22^ManagementCert.(1)Other^10^53Masters( HealthAdmin. (5);Educ.Admin.(3);AdultAdmin.(1);BusinessAdmin.(1).Doctorate^0^0The fact that the large proportion (85%) of the sampled CNEs either hold amaster's degree or are in the process of obtaining graduate level preparation supports theobservation that the trend of the past 15 years is for more CNEs to be prepared at themaster's level. The results of the current study, for example, are consistent with recentsurveys such as that by Sorrentino (1992), in which 82% of the CNEs held masters38degrees, but very different from older surveys such as that by Stevens (1977), in whichfewer than 20% of the sampled CNEs held advanced degrees. A striking proportion(60%) of the CNEs in the current study have or are pursuing postgraduate education indisciplines other than nursing. This finding is similar to, and even more extreme than,that of Sorrentino (1992), in which the advanced degrees held by CNEs included theMSN (41%), but also the MHA (23%) and the MBA (18%). These results raise thequestion as to why so many CNEs choose to obtain graduate education in disciplinesother than nursing. There may be several possible explanations for this finding. First,nurses may wish to maintain some flexibility with respect to career opportunities in areasother than nursing. Furthermore, an individual may have initially had an interest in aspecific area, such as nursing education, at the time of graduate studies but subsequentlymade a shift to nursing administration. Finally, it is possible that nurses specificallyinterested in nursing administration feel satisfied with their knowledge of nursing, butfeel a gap in their business knowledge and, therefore, choose a degree in business orhealth administration.Age and Gender of CNEs Most of the CNEs (83%) were between the ages of 40 and 54 years, the majorityin their late 40s (Table 4). None was less than 34 years old and only one was older than55. All of the respondents were female.The fact that most CNEs are mature is perhaps expected of persons in such asenior executive position, and is consistent with the results of other surveys of CNEsincluding those by Moore et al. (1988) and Poulin (1984b). Of the three CNEs who areless than 40 years old, two hold posts in smaller (100-199 beds) community hospitalswhere the responsibilities of the CNE may not be as great as in larger hospitals. That all39of the respondents in the current study are female is somewhat surprising. Other studies,such as those by McKay (1971) and Moore (1988), have reported that, although there arefew male nurses (roughly 3% of all nurses are male), there has been a disproportionatenumber (6 to 7%) of men in senior administrative positions. Therefore, it is possible thatthe results of this study reflect the improving status of women within nursing and societyin general.Table 4Age Range of CNEsaAge in Years Frequency Percentage< 25 0 025 to 29 0 030 to 34 0 035 to 39 3 1640 to 44 5 2545 to 49 7 3750 to 54 4 2155 to 59 1 .05> 60 0 0a n=20Number of Years in Present PositionAs shown in Table 5, most of the respondents (80%) had held their current position formore than a year, and 12 (60%) had held the same position for 4 to 6 years. This finding isconsistent with the reports of Henry and Moody (1986), Moore et al. (1988), and Poulin (1984b)in which the average tenure of CNEs was found to be between 4 and 5 years. However, giventhe current dramatic reorganizations occurring within health care and the hospital sector in40particular, one might question whether turnover rates for the CNE position will increase. The factthat 20% of the respondents had held their positions for less than one year may be an indicationthat turnover has, in fact, already increased.Table 5Tenure in Present PositionsYears^Frequency^PercentageLess than 1^4^201 to 3 4 204 to 6^12^60Ito 10 0 0More than 10^0^0a n=20Number of Years in Nursing AdministrationMost of the CNEs had considerable experience within nursing administration, asshown in Table 6. Sixty-five percent had between 11 and 20 years of experience and 20%had between six and ten years of experience. These findings are not particularlysurprising. It is reasonable to assume that in order to obtain the position of CNE, thenurse administrator would have to first demonstrate competence at various manageriallevels. For example, the large proportion of the sampled CNEs had occupied positionssuch as head nurse, program co-ordinator, and director of nursing before assuming theposition of CNE. This finding supports that of Freund (1985) who reported that 73% ofCNEs had 15 years or less of management experience within nursing. A small proportion(10%) of the sampled CNEs, however, had relatively little experience (one to five years)in nursing administration before assuming the CNE position. The two CNEs in this group41were responsible for administering small community hospitals (approximately 100 beds)and were prepared at the masters level. This may suggest that the educational preparationof these individuals compensated for their lack of experience and was instrumental intheir securing the position of CNE.Table 6Years in Nursing AdministrationsYears^Frequency^PercentLess than I^0^01 to 5^2^106 to 10^4^20II to 15^7^3516 to 20^6^30More than^1^.05a n=20Current and Future Knowledge and SkillsThe perceived importance of defined knowledge/skills for sucessful performanceby the CNE now and in the future was examined. Each individual knowledge/skill (KS)was rated by each respondent from "not important" (1) to "very important" (5). Rawscores for current and future rankings are presented in Appendices E and F. Mostrespondents rated the KSs between 2 and 5 overall. Very few ratings of "not important"were recorded, even for the lowest ranked KSs. Some respondents consistently rated allKSs high ( one respondent gave no lower than a rating of 4) whereas others recorded42a balance of ratings (e.g., another respondent rated 30 of the 48 KSs as less than orequal to 3).The rank of each KS was determined on the basis of its average (aggregate)rating and the rank of each knowledge/skill group (KSG) was determined on the basis ofthe average rating for the KSs within the group. For certain KSGs, the KSs within thegroup were of similar average ratings (and overall ranks), but for most KSGs, the ratingsand ranks of individual KSs within the group varied markedly. Because of this markedintra-group variability, and because the groupings are somewhat arbitrary in any case,the analysis focuses on individual KSs rather than the KSGs with which they areassociated. The average ratings and the ranks of the current and future KSs and KSGsare presented in Table 7.The three Communication Skills (written, spoken, and public relations) wereranked high in the top third (i.e., ranks 1-16) in current importance by all respondents.Of the Social Science Skills, the ability to manage change and to participate in positiveperson-person relations and group dynamics were similarly highly ranked, but theremainder of this group were ranked in the middle (i.e., ranks 17-32) and lower third(i.e., ranks 33-48). Of the Management Functions, five of seven KSs were ranked withinthe top third; the remaining two (accounting and purchasing) were ranked much lower,in the bottom third. Within the KSG, Knowledge of the Organization, knowledge of twotypes of health care organizations ( general acute hospitals and ambulatory careprograms) were ranked highest, but knowledge of other health care environments andprograms were considered less important. This result is perhaps expected of these CNEswho were selected from general hospital acute care settings only.Among the KSs included in the KSG, Nursing Knowledge, nursing theories and43Table 7Rank Order of Importance of Current and Future Knowledge/SkillsKSs and KSGs CurrentMean Score RankFutureMean Score RankCOMMUNICATION SKILLS 4.74 4.83Written communication 4.79 2.5 4.80Public relations 4.74 4 4.75 7.5Spoken communication 4.68 5.5 4.95 4SOCIAL SCIENCE SKILLS 4.16 4.60Managing change 4.79 2.5 5.00 2Person-person relations & groupdynamics 4.68 5.5 5.00 2Social & cultural aspects of health& illness 4.05 19 4.60 14Health economics 3.84 24 4.45 18.5Health promotion skills 3.42 37 3.95 34MANAGEMENT FUNCTIONS 4.09 4.12Problem solving & decision makingmethods 4.95 1 5.00 2Budget preparation & analysis 4.63 7.5 4.70 11.5Labour relations & collectivebargaining 4.47 9 4.30 21.5Personnel administration 4.26 12 4.10 30.5Management theories and methods 4.21 14.5 4.55 15.5Accounting principles 3.50 35 3.65 37.5Purchasing principles 2.58 47.5 2.60 46KNOWLEDGE OF THE 3.77 4.25ORGANIZATIONGeneral acute hospitals 4.63 7.5 4.70 11.5Ambulatory care programs 4.16 16.5 4.75 7.5Long term care facilities 3.84 24 4.25 24Mental health programs 3.79 26.5 4.45 18.5Regional services 3.78 28 4.53 16Provincial/federal health sevices 3.67 31 4.05 33Rehabilitation programs 3.61 32 3.89 36Public health units 3.37 38 4.25 24Specialized hospitals (e.g., cancer) 3.05 43 3.35 4244Table 7 (continued)Rank Order of Importance of Current and Future Knowledge/SkillsKSs and KSGs CurrentMean Score^RankFutureMean Score^RankNURSING KNOWLEDGE 3.77 3.95Nursing theories 4.26 12 4.30 21.5Issues & trends in nursing 4.16 16.5 4.25 24Nursing research 3.79 26.5 4.10 30.5Nursing research utilization 3.68 30 4.10 30.5Clinical expertise 2.95 44 3.00 45ANALYTICAL METHODS& SKILLS 3.58 4.16Evaluation methods 4.11 18 4.70 11.5Interpretation of statistical data 4.00 20 4.40 19Health services planning methods 3.84 24 4.50 17Operations research 3.74 29 4.10 30.5Computer applications 3.53 34 4.35 20Statistical & quantitative methods 3.26 39 3.60 39Epidemiology 2.58 47.5 3.50 40HEALTH SERVICESKNOWLEDGE 3.58 4.08Government health policy 4.42 10 4.70 11.5Health services planning issues 4.26 12 4.85 5Health ethics 4.21 14.5 4.74 9Canadian health care trends 3.95 21.5 4.21 26Health law 3.95 21.5 4.20 27Community involvement in healthservices 3.58 33 4.55 15.5Health services & social policies 3.47 36 4.15 28Medical science & technology 3.17 40 3.21 44Environmental factors affectinghealth care 3.16 41 3.65 37.5Health maintenance & prevention 3.11 42 3.90 35International health care trends 2.89 45 3.45 41Current epidemiological information2.79 46 3.30 4345issues and trends in the profession were considered important, though low in the topthird, whereas nursing research and research utilization were ranked of only moderateimportance, low in the middle third. Clinical expertise ranked 44th in current importanceoverall, but there was more disagreement on this point than others. Whereas somerespondents rated this skill as "not important," others rated it as "very important." Theseresponses appear to correlate with the educational background of the CNEs. For the fourCNEs holding the BSN degree, the average rating for clinical expertise was 4.0, and twoof the four rated this KS as "very important" (5). For the fourteen CNEs with graduatedegrees, the average rating for clinical expertise was only 2.7. None of the AnalyticalMethods and Skills fell within the top third of KSs. Although most were ranked as of atleast moderate importance, epidemiology ranked lowest in the bottom third. In the HealthServices Knowledge KSG, only three of twelve KSs (government health policy, healthservices planning issues and health ethics) ranked within the top third overall. Themajority of the KSs in this KSG were in the bottom third.For most KSs, the average rating of "future importance" is greater than that for"current importance." When their current and future ranks (C/F) are compared, thefollowing KSs are perceived to be more important in the future (change in rank):computer applications (34/20); knowledge of regional services (28/16); knowledge ofambulatory care programs (16.5/7.5); health services planning methods (24/17); socialand cultural aspects of health and illness (19/14); health economics (24/18.5); andprogram evaluation methods (18/11.5). The fact that the majority of KSs are perceivedby the sampled CNEs to be more important in the future suggests that this group ofCNEs believes that CNEs of the future will, in general, have to be more knowledgeablein order to be successful than those occupying the position today.46Four KSs decreased in projected future importance (change in rank): labourrelations and collective bargaining (9/21.5); personnel administration (12/30.5); nursingtheories (12/21.5); and issues and trends in nursing (16.5/24).Communication Skills are clearly critical for the CNE. They rank highest interms of both current and future importance and the ratings given these by individualCNEs are very similar. Spoken communication, which was defined as talking, listening,and public speaking, ranks highest (5.5/4.0). Written communication and report writing(2.5/6.0), and public relations (4.0/7.5) are ranked only slightly lower. Exactly whycommunication skills are ranked high and what it may mean is not clear. Do CNEsperceive that they require especially sophisticated communication skills or is this an areawhich is seen to be under-emphasized in educational programs? Does the emphasis placedby the CNEs on communication skills reflect the fact that they are masters of these skillsor find them difficult to master? Are there certain skills of particular importance ordifficulty, such as writing longer reports or public speaking, which are not currentlytaught but which should be? Person-person relations and group dynamics, which lieswithin the KSG of Social Science Skills, was also highly ranked, and might be consideredamong the communication skills.Thus, many of the above comments and questions applyto this KS as well. Katz (1974), who terms such communication and social science skills"human skills," notes they are of particular importance to the effective functioning ofmiddle managers. He also notes, however, that inter-group skills (i.e., with otherdepartments and/or organizations) as opposed to intra-group skills (i.e., within nursing)are more important in successively higher levels of management. Whether groupdynamics, as assessed in the questionnaire, was interpreted by the sampled CNEs to meanthe former or the latter is not clear. However, there are indications, such as those noted47above, that the orientation of CNEs may be shifting to a larger role outside of the nursingdepartment. Nonetheless, whether the CNE's position requires that an emphasis be placedon either inter-group or intra-group communication, it is clear that the role is obviouslyan integrated one requiring contact and, likely, consultation with others.Management knowledge and skills which lie within the KSGs of ManagementFunctions and Analytic Methods and Skills are also consistently ranked high inimportance (i.e., within the top two-thirds). In Katz's classification, many of these highlyranked skills are considered technical, and more consistent with middle rather than upperlevel management functions. These include problem solving and decision makingmethods, management theories and methods, evaluation of programs and quality of care,health services planning methods, personnel administration, labor relations and collectivebargaining, financial management and budgeting, and computers and health informationsystems. That this wide range of skills is considered important supports the notion thatthe modern CNE must demonstrate considerable expertise in management. Nevertheless,some delimitation of the expected expertise is apparent. For example, whereas financialmanagement and budgeting are deemed important, accounting and purchasing principlesare not. This may suggest that CNEs believe that these latter skills, which could beconsidered highly specialized, are best left to others who can serve as consultants to theCNE if need be.Of these middle management skills, some appear to be of increasing importancein the future (evaluation and planning methods and computers), and others of decreasingimportance (personnel administration and labour relations and collective bargaining). Thecurrent emphasis on evaluation and planning methods may be a response to fiscal restraintin the health care sector, and is consistent with a trend towards recognition of the48importance of outcome evaluation within the sector generally. The decrease in futureimportance of personnel and labor issues may indicate that CNEs predict that these issueswill be delegated to specialists. In addititon, more congenial relations betweenmanagement and labour may be anticipated in the future.That computers are of increasing importance to CNEs has been acknowledged bythose sampled (KS ranks 34/20), but the relatively low current rank seems curiously outof step with the views of many other groups, including business managers, who havebeen quick to embrace the technology. Perhaps the delayed introduction of computers tomuch of the health care sector (relative to business), and the fact that many CNEs wereperhaps not exposed to computers during their education may explain this. Acontradictory and possibly less plausible explanation may be that computer skills areconsidered so routine that they do not warrant additional attention in and of themselves.According to Katz (1974), conceptual skills are of particular importance to theeffective functioning of senior executives. Key among these skills is the ability tounderstand the organization as a whole and to recognize the relationship between theorganization and its broader context which includes the health care sector and the largerpolitical, social, and economic mileiu of which it is a part. He notes that by recognizingthese relationships, the senior executive should be able to act in a way which advancesthe organization.There are several indications that the CNEs increasingly recognize the importanceof understanding the broader context of health care and the forces which shape it. Chiefamong these forces are the recession and the size of government deficits which togetherhave forced both federal and provincial governments to reduce health care funding andto reorganize the delivery of heath care dramatically. The CNEs appear to acknowledge49these forces and the importance of understanding them, inasmuch as they rankgovernment health policy and health services planning issues of high and/or increasingimportance. On the other hand, those KSs which address some of these issues from aneven broader perspective were not highly ranked. These include international health caretrends and Canadian health care trends. It should be noted that the CNEs were not askedwhat was of interest to them, but rather what was important to successful performancein their careers. These results may indicate lack of interest or vision on their part or arealistic focussing of their attention at a regional level.The CNEs' responses appear to indicate a recognition of the emergence of newissues in health care reform. One is the increasing involvement the public will have inhealth care delivery, especially at the local level--community involvement in healthservices rose from 33 to 15.5 (current to future importance). Similarly, the fact that theCNEs also ranked the KS social and cultural aspects of health of increasing importance(19/14) suggests a recognition of the progressively multicultural composition of thepopulation and/or a greater sensitivity to cross-cultural issues. Health ethics was rated ofincreasing importance (14.5/9) reflecting the increasing prominence ethical issues havein directing health policy and the administration of health care.It appears that CNEs also recognize some structural changes in the health caresystem which have been or will be introduced. Knowledge of both regional andambulatory health care delivery systems, for example, move up in rank from current tofuture importance ( 28/16 and 16.5/7.5, respectively) at a time when the transition fromacute care to these alternative settings is proceeding briskly. Similarly, the term,"community involvement in health care," implies not only a force for change as describedabove but, with the proposed lay advisory health boards in British Columbia (Seaton et50al. 1991), a real change in health care management structures and power relationships.The CNEs not only recognize the forces and nature of change, but also indicatethe importance of managing change. This KS was top ranked (2.5/2.0) in both currentand future importance. Are the changes unwelcome (e.g., hospital closures) and to bemanaged defensively or generally welcomed as opportunities to be constuctivelyexploited? Further, to manage change could be understood in a "passive" sense, whereas"to initiate change" is clearly "active." Katz (1974) suggests that of the two, initiation ofchange requires different qualities and more skill. Are CNEs in a position to initiatechange? Do they intend to? And if so, do they demonstrate the necessary attitudes andskills? There are perhaps some indications that CNEs may be moving, or at least see theneed to move, from a passive to a more active stance regarding the management ofchange. For example, whereas the KS health services planning issues (passive?) wasconsistently ranked highly, health services planning methods (active?) was not rankedhighly in current importance, but was in future importance (24/17). It would beinteresting, therefore, to clarify the role CNEs perceive themselves playing in the futureon behalf of the nursing organization and nursing profession in the midst of the changesoccurring in the health care system.Whether CNEs require a perspective that is unique to nursing is controversial.The sampled CNEs ranked the collective nursing KSs low in both current and futureimportance. Although the perceived importance for the KSG Nursing Knowledge issomewhat higher in the future (3.77/3.95), its perceived importance to the other KSGsin the future is significantly lower. Even the two nursing KSs which ranked within thetop third of current importance (issues and trends in nursing and nursing theories) fellsubstantially in terms of future importance (16/24.0 and 12/21.5, respectively). This may51represent a particular bias of this group of CNEs especially since 60% have graduateeducation in disciplines other than nursing, a new cycle in academic fashion, a morepragmatic attitude toward nursing in response to fiscal restraint, or something elseentirely. Whatever the reason, these results contradict the opinions of writers such asCleland (1984), Simms (1988), and Stevens (1979) who have suggested that knowledgeof nursing theory is critical for the effective CNE.There may be several plausible reasons for this finding. First, the developmentof new management stuctures might change the CNEs' focus and allegiance. Forexample, as nursing and other hospital administrative sections become leaner and lessmonolithic and organizational structures flatten, it seems likely that senior administratorsmight work more closely together on behalf of the organization and less on behalf oftheir respective departments. In a similar fashion, the increasingly popularmultidisciplinary program management models emphasize responsibility to the programand may shift nurse executives' attention and allegiance from the nursing department tothe program in which they are involved. Alternatively, the fact that nursing knowledgeis not ranked highly by this group of CNEs may reflect a predictable bias of the groupbecause the majority of them who have graduate education were educated in programsother than nursing. Of the fourteen CNEs who held graduate degrees, ten were educatedin other disciplines. These ten might have chosen to pursue non-nursing degrees as aresult of a negative bias towards graduate level nursing knowledge or might havedeveloped such a bias as a result of their education. Furthermore, the lack of availabilityof MSN programs in many areas of Canada may have been a significant factor inselecting a non-nursing degree.The CNEs also de-emphasized nursing research and research utilization in52relation to many of the other KSs in both the current and future KS assessments. Whetherthis represents a lack of insight into the importance of nursing research, a lack of intereston the part of the sampled CNEs, or a lack of opportunity and/or funding to pursueresearch is not clear, though certainly the latter two are factors in the current climate ofrestraint. Another explanation may be related to the educational backgrounds of thesampled CNEs. For example, 30% of the sampled group were not prepared at thegraduate level and of the 75% who had graduate education, only 22% held an MSN. Thismay suggest that only a small percentage of the sampled CNEs (i.e., those with an MSN)are knowledgeable about research and particularly nursing issues which warrant research.Moreover, in some institutions, clinical nurse specialists have assumed responsibiity forconducting nursing research as well as promoting research-based practice. As a result,the CNE may not consider research an intergral part of the CNE role. However, the factthat even operations research ranked poorly tends to contradict this last explanation.Nonetheless, the lack of research emphasis may be shortsighted. Indeed, some writerssuch as Dick (1992) and O'Brien-Pallas (1992) have argued that it is imperative toconduct nursing research, now more than ever, to establish the profession's role anddirection in the midst of a rapidly changing health care environment. For example, itappears that nursing and its relationship to other disciplines is changing and will continueto do so.Other changes involve the nursing profession in a broader sense. Some of thesewill undoubtedly be negative. The Seaton Report (Seaton et al. 1991), for example,recommended increasing the numbers of non-professional nursing personnel, and did notsupport the BSN as the minimum preparation for licensure. On other fronts, however,the profession seems poised for gains. One example is the proposed licencing of nurse-53midwives in British Columbia. Another is the proposed development of nursing-onlyemergency telephone and clinic services in Quebec (Medical Post, 1992). Furthermore,given the increasing emphasis being placed on the evaluation of programs, systems andthe measurement of tangible outcomes of care, it is important that CNEs create aninfrastructure within their organizations which supports nursing research and promotesthe utilization of research findings.Clinical expertise ranked very low in terms of current and future importance(44/45), as did related skills such as health promotion (37/34) and health maintenance andprevention (42/35). Moreover, of the few CNEs who rated such skills as important, mostwere unusual in that they had no graduate level education and therefore may have hada stronger clinical orientation as opposed to a theoretical focus. That the majority ofCNEs rated clinical skills of lesser importance is consistent with the observations ofPoulin (1979), Stevens (1979), and Price (1984) who have documented the progressiveseparation of management and clinical functions within the nursing hierarchy. However,it runs counter to the claims of others such as Fine (1978), McClure (1985), and Nyberg(1982) who have suggested that clinical expertise is critical to the functioning of theCNE.Finally, some KSs which ranked very low might be considered outliers in thesense that they do not fall within the usual purview of the CNE. These are perhaps bestleft to others to master and might be accessed by the CNE as necessary throughconsultation with others, both within the organization and externally. Among these areepidemiology, statistics, economics, health law, and accounting principles.Comparison with the CHAS Study: 1981 vs 1993 In the CHAS study (Hastings et al. 1981), a total of twelve KSs were ranked54within the "top ten" lists for CNEs working in either teaching hospitals or large hospitals( > 200 beds). Nine of these skills also ranked within the top ten of current importancein the present study (Table 8). If nursing knowledge is excluded from consideration (asit was not assessed in the CHAS study), and a comparison is made of the top ten rankedskills of the 1981 study to those of the present study, the following pattern emerges:What might be considered "core" management and communication skills were importantin 1981 and remain important now. These include problem solving and decision making,managing change, the three communication skills, person-person relations and groupdynamics, budget preparation and analysis, labour relations and collective bargaining, andmanagement theories and methods. Five KSs are now considered more important thanthey were in the 1981 study. They include health services planning issues, governmenthealth policy, personnel administration, knowledge of ambulatory care programs, andhealth ethics. On the other hand, current CNEs in British Columbia value knowledge ofhealth maintenance and prevention much less and knowledge of health law somewhat lessthan did the group surveyed in the CHAS study.Time DemandParticipants were asked to estimate how much time (as a proportion estimated tothe nearest 20%) they spent using each of the knowledge skill groupings (i.e., inclusiveof any KS within that group). As previously reported, the importance of KSs within aKSG may vary widely. It might be expected, therefore, that the time demand ofindividual KSs might also be variable, but it was not feasible to assess time demand forindividual KSs. To calculate the mean time demand for each KSG, each 20% timeinterval was represented by its midpoint value.55Table 8Comparison of the Top Ten Knowledge/Skills of the CHAS Study and the Current StudyKnowledge/Skills Ranks Ranks RanksCHAS Study CHAS Study Current StudyTeaching Hospital Large HospitalProblem solving &decision makingmethods5 2 1Managing change 1 6 2.5Writtencommunication4 5 2.5Public relations 6 9 4Spoken communication 2 3 5.5Person-personrelations & groupdynamics10 10 5.5Budget preparation &analysis8 6 7.5Labour relations &collective bagaining8 9Management theories 9 10& methodsThere was no provision for respondents to indicate more precise responses such as"never" or "all of the time." It was acknowledged in the questionnaire that multiple KSsfrom the same and/or different KSGs would likely be used concurrently rather thansequentially and the fact that the average "total" time demand per respondent was 330%supports this contention.As shown in Table 9, the CNEs reported they used communication skills mostof the time (68%); and both management abilities and knowledge of the organization toa similar extent (60% each). But they used knowledge of nursing, health services, social56sciences, and analytic skills considerably less often (34% to 37% each). The KSGcurrent importance and time demand rankings are generally consistent and would seemto indicate that the perceived importance of a KSG is correlated with its time allocation.The one exception is social science skills which ranked second in importance, but lowin time demand.Table 9Knowledge and Skill Time DemandKSGs0-20% 21-40% 41-60% 61-80% 81-100%MeanPercentCommunication 0 10 20 20 45 68SkillsSocial Science Skills35 25 30 5 5 34Management 0 30 15 35 20 60FunctionsKnowledge of the 5 20 25 20 30 60OrganizationNursing Knowledge 30 35 25 5 5 34Analytical Methods 30 35 15 10 10 37& SkillsHealth Services 32 16 26 16 5 37KnowledgeThe discrepancy may be related to the fact that only two of five KSs within this groupwere highly ranked individually (managing change and person-person relations and groupdynamics), and these might reasonably be grouped with management functions andcommunication skills, respectively. Moreover, by their nature some KSs may be requiredinfrequently or for short periods but be important nonetheless. The ability to manage57change may be one of these. On average, nursing knowledge was used a relatively smallproportion of the CNEs' time (34%), with only 10% of those sampled using thisknowledge more than 60% of the time and 30% of respondents using this knowledge lessthan 20% of the time. The allocation of time to nursing knowledge corresponds with itslow rank in terms of the current knowledge/skill importance noted previously. Clearlythen, nursing knowledge is not of first rank importance to the CNE. However, aknowledge base called upon infrequently, even 20% to 30 % of the time, seems likelyto be critical to the position, and seems to suggest that CNEs should at least have anursing background or knowledge of nursing. To the extent that the sampled CNEs de-emphasize nursing knowledge, their opinions run counter to those of others. Forexample, Jackson (1988) and Poulin (1984b) claim that advanced nursing knowledge isrequired by the CNE so that the role of nursing can be interpreted for others and theknowledge used as a framework for the application of business knowledge in the nursingcontext.When comparing the time demand of the KSGs to Katz's (1974) classificationscheme the several findings are notable. Technical skills (i.e., the KSGs of ManagementFunctions, Analytical Methods and Skills, Nursing Knowledge) were used the most often(131%), followed by human skills (i.e., the KSGs of Communication Skills and SocialScience Skills) (102%) and lastly, conceptual skills (i.e., the KSG of Knowledge of theOrganization) (97%). This finding relates to Katz's (1974) description of seniormanagers. Katz clearly states that the most important skill required of senior managersis the ability to see the organization as a whole as well as understand the impact of avariety of forces, both internal and external, on its operations. However, he alsorecognizes that senior managers of smaller organizations may be required to possess58greater technical expertise than their counterparts in larger organizations simply becausethe necessary human resources may not be available to them. The largest proportion ofthe CNEs in this study (40%) were from small hospitals, ( i.e., 100 to 200 beds).Course SuggestionsThe respondents were asked to rank the importance of 20 graduate level courseschosen from among those offered in nursing (MSN; 4 courses), commerce (MBA; 4courses), and health administration (MHA; 12 courses) at The University of BritishColumbia for the successful performance of their current position. Although the courseswere listed in the questionnaire without reference to discipline, this information isprovided in Appendix G. An examination of the course descriptions in the Universitycalendar indicates there is some overlap in course content. Moreover, the courses do notcorrespond exactly with individual KSs or even KSGs. There are, for example, nocourses which correspond to two of the KSGs (communication skills and social scienceskills). Respondents rated each course from "not important (1)" to "very important (5)."The courses were then ranked on the basis of their mean ratings which ranged from 3.05to 4.70.As shown in Table 10, three of four (75%) of the MBA courses, six of twelve(50%) of the MHA, but only one of four (25%) of the MSN courses fell within the topten rank. The remaining three nursing courses ranked in the bottom third. The courserankings seem generally consistent with KS importance, especially with respect to thefuture. What might be classified as general management and health management courseswere consistently highly ranked. These include some courses of a more technical naturesuch as Health Care Management, Managerial Decision Making, Financial Managementin Health Care, Personnel Management, and Management of Labour Relations. These59Table 10Ranking of Selected Courses from the Disciplines of Nursing. Commerce. and HealthAdministrationCourse Mean Score RankHealth Care Management 4.70 1Managerial Decision Making 4.65 2Health Management Issues 4.47 3Planning for Health Services 4.45 4Financial Management in Health Care 4.40 5Analysis of Health Care Organizations 4.32 6Personnel Management 4.25 7Health Policy & Analysis 4.15 8Management of Labour Relations 4.10 9Nursing & the Delivery of Health Care 4.05 10Health Information Systems 3.84 11Health Law 3.75 12Canadian Health Services 3.53 13.5Critical Thinking in Nursing Practise 3.53 13.5Nursing Research 3.42 15Statistics for Health Research 3.30 16Theory Development in Nursing 3.16 17Managerial Accounting 3.05 19Epidemiology 3.05 19Socio-Economic Factors & International Health 3.05 19Developmenthighly ranked management courses also include some with a more analytical orconceptual emphasis which address the broader context of health care, reinforcing thefact that CNEs seem to feel it is important to have a more global perspective on healthcare issues. Among these are Health Management Issues, Planning for Health Services,60Analysis of Health Care Organizations, and Health Policy and Analysis. The highrankings for these courses may also suggest that CNEs see the need to play a moreproactive role in initiating changes within nursing which are consistent with provincialdirections for health care reform. Notably, courses which address issues from a national(Canadian Health Services), and international (Socio-Economic Factors and InternationalHealth Development) perspective are ranked much lower. This is also consistent with thelower ranks of the knowledge/skills which correspond to these courses (i.e., Canadianhealth care trends and international health care trends) thereby reinforcing the notion thatthe sampled CNEs are less focused on changes occuring at a much lower level and donot perceive this as a high priority for future CNEs. The course entitled HealthInformation Systems is ranked of moderate importance, which is consistent with thefuture ranking of the KS computer applications. Each of Statistics for Health Research,Managerial Accounting, and Epidemiology courses rank low both in perceivedimportance and educational recommendations. However, it cannot necessarily beconcluded from this report that the CNEs feel the course that ranked last should not orneed not be taught, but only that the course content is of relatively lower priority fortheir current position than that in higher ranked courses. The low priority given tonursing courses (and nursing research) is consistent with the CNEs' perception that suchknowledge will be less important in the future in comparison with the other KSGs.Only one nursing course (Nursing and the Delivery of Health Care) ranked in thetop 50% of educational recommendations. These findings run counter to the opinons ofseveral writers. Fralic (1987), for example, suggests that the content of nursingadministration programs should emphasize business and management courses within anadvanced nursing core which includes research, issues, roles and nursing theory.61Similarly, Carroll (1992) recommends a dual degree program which encompasses anMSN and an MBA and Lancaster (1986) and Simms (1988) suggest the inclusion ofspecific non-nursing courses such as health economics, cost accounting, health policy andplanning ,and computer and information technology. One possible explanation for thisfinding could be the fact that because only 22% of the sampled CNEs held an MSNdegree, the majority of the sample may not have had an understanding of the content ofthe nursing courses thereby ranking them of relatively lower importance. Further, thepossibility of CNEs with alternate training, such as non-nurse CNEs with rudimentarynursing knowledge or with such knowledge available to them through consultation cannotbe dismissed altogether. Nonetheless, these data appear consistent with the opinion thatthe prospective CNE must have a background in nursing but that graduate level educationcould focus on skills other than nursing, such as, management skills.SummaryIn this chapter, the findings of the study have been presented anddiscussed. Several themes emerged from the demographic and knowledge/skill data.The CNEs in general were a well-educated group, most prepared at the masterslevel but not within nursing. Most had held the same position as CNE for an average offour to six years, and had a significant amount of experience in nursing administrationbefore assuming the position of CNE.With respect to the knowledge/skill, course and time demand data, severalfindings are significant. Communication skills and middle management skills wereconsistently ranked highly as was the time demand associated with them. Managementfunctions were also highly ranked. The sampled CNEs appear to value conceptualabilities and felt these skills should be formally taught. CNEs seem to recognize the62issues surrounding health care reform within the province but placed relatively lowemphasis on knowledge of national and international health care trends. Management ofchange within the organization was highly ranked, perhaps as a result of the health carereform process; however, it was not clear whether change was embraced or if the CNEswere merely attempting to manage the changes imposed upon them. Lastly, the need forthe effective CNE to possess nursing knowledge was perceived to be less important.Nursing knowledge was ranked low in the present (as was the time demand) and evenlower in the future in relation to the other KSGs.63CHAPTER FIVESUMMARY, CONCLUSIONS, IMPLICATIONSSummaryChanges within the Canadian health care system have affected and will continueto affect the role of the CNE, but exactly how and to what extent is not known. Yet thisinformation is important to administrators and nurses and especially educators responsiblefor the preparation of prospective CNEs. The lack of data relevant to the Canadiancontext in particular is striking. The most current Canadian survey of CNEs wasconducted almost fifteen years ago (CHAS, 1978). Moreover, although practicing CNEsare in an excellent position to speak to these issues and to advise educators regardingeducational priorities, their opinions have seldom been sought. The motivation for thisstudy, therefore, was to develop a descriptive data base with respect to the knowledgeand skill required of these CNEs as well as their recommendations for the educationalpreparation of future nurse administrators. The following information was obtained froma survey of CNEs employed in acute care hospitals of more than 100 beds in BritishColumbia: personal and institutional demographic data; rankings of the importance ofvarious knowledge and skills to CNEs currently and in the future; time spent using thevarious knowledge and skills; and rankings of the perceived relevance of 20 graduatelevel courses offered in nursing, commerce, and health administration.Twenty-four (58.6%) of the 41 CNEs surveyed responded; 20 (49%)questionnaires were suitable for analysis. The responses were analysed within the contextof the managerial classification scheme as proposed by Katz (1974). The CNEs workedin acute care general hospitals ranging in size from 100 to more than 400 beds; themajority held masters degrees and were responsible for nursing as well as other patient64care areas. Most of the CNEs were in their mid to late 40s, all were women, and asignificant proportion had extensive administrative experience.The ranking of the importance of various KSs indicates that communication skillshave played and will continue to play a significant role in the CNE position asdemonstrated by their high ranks in the past (CHAS, 1978), present and future. Severalmiddle management skills, termed technical skills in Katz's classification scheme, werealso seen as critical to the role. These were also ranked high in the past, present andfuture. Within this group of skills, evaluation and planning methods and computersincreased in importance as indicated by rankings while personnel administration andlabour relations and collective bargaining were lower in rank. The CNEs also viewconceptual skills as important. This is reflected in the high ranks of KSs such asknowledge of general acute hospitals, ambulatory care programs and regional services,government health policy and health services planning issues. These CNEs appeared tounderstand the broader context of health care and the forces which have an impact on it,as indicated by the high ranks of the conceptual knowledge/skills noted above; however,knowledge of a broader context of health care such as the Canadian health care systemor of international health care trends was not deemed important for the CNE. Theemphasis placed by the CNEs on the importance of knowledge of ambulatory careprograms, regionalization of health services, social and cultural aspects of health andillness and evaluation methods suggests that they recognize the shape that health carereform is taking within the province. Management of change within the organization wasvery highly ranked as a need for both the present and the future. Finally, the importanceof nursing knowledge for successful performance of the CNE role was somewhatcontroversial. The need for nursing knowledge overall was ranked low in the present and65even lower in the future although the KSs nursing theories and issues and trends innursing were seen as being of moderate importance.The time CNEs spent using the various KSs was, for the most part, consistentwith the KS rankings. The KSGs of Communication Skills, Management Functions andKnowledge of the Organization all ranked high in time demand. Conversely, NursingKnowledge was used a relatively small proportion of the time. The one discrepancybetween the rank of the KSG and the proportion of time allocated to using specific KSswithin the KSG is with respect to the KSG of Social Science Skills. Although SocialScience Skills ranked second in importance, the time demand was disproportionately low.A possible explanation for this discrepancy may be related to the fact that only two offive KSs within this group ranked highly (managing change and person-person relationsand group dynamics). Furthermore, by their nature these KS may be requiredinfrequently but be important nonetheless.Lastly, the rankings of the courses, in general, were consistent with the KSimportance, particularly with respect to the future. Several management courses wereranked highly by the CNEs. These included Health Care Management, ManagerialDecision Making, Financial Management in Health Care, Personnel Management andManagement of Labour Relations. Courses of a more conceptual nature were also seenby the CNEs to be important. These included Health Management Issues, Planning forHealth Services, Analysis of Health Care Organizations and Health Policy and Analysis.Notably, courses which address issues from a national and international perspective wereranked low (Canadian Health Services and Socio-Economic Factors and InternationalHealth Development). Nursing courses in general were given low priority. The oneexception was the course Nursing and the Delivery of Health Care which ranked in the66top 50%.ConclusionsBased on the findings of this study, the following conclusions are presented.1. Position titles indicate that CNEs are assuming a broader span of control. There areindications that the focus of the CNE's orientation may be shifting from the nursingdepartment and nursing issues to multidisciplinary programs, the whole organization andthe broader context. The most common title is Vice President Patient Care Service.2. Katz's managerial classification scheme provided a useful framework to analyse therole of the CNE.3. CNEs identify the ability to communicate effectively, both verbally and in writing, asthe most important KS.4. The CNEs project that Conceptual Skills, which are characteristic of seniormanagement positions, will be of increasing importance to CNEs in the future.5. The managerial skills described by CNEs as important currently are primarily oneswhich are important for middle management positions and are termed in Katz's scheme"human" and "technical" skills.6. There is a broad range of managerial skills and expertise which CNEs see as importantfor the effective CNE to master. These include the following: the ability to solveproblems, make decisions, and manage change; to communicate effectively; to maintaingood person to person relations and function well as part of a group; to understand anduse management theories and methods; and to prepare and analyze a budget.7. Some skills such as accounting and statistical and epidemiologic methods are seen asof minimal importance for the CNE and are perhaps best left to others.8. The efforts of CNEs seem to be shifting from "managing change" in a passive or67reactive sense to "initiating change" which is more proactive.9. CNEs seem to be knowledgable of provincial health care trends such as regionalizationof health services, emphasis on ambulatory care, greater community and lay involvementin health care and emphasis on outcomes evaluation.10. The CNEs recognize the (increasing) importance of understanding the broad contextof health care, including the forces which shape it, especially at the provincial level.11. CNEs use nursing knowledge a substantial proportion of the time, but they place arelatively low value on advanced nursing knowledge and project that this knowledge willbe of even less importance in the future in relation to the other KSGs.12. The responses of CNEs indicate that graduate education of prospective CNEs shouldfocus on management and health administration primarily, with less emphasis on nursingknowledge.ImplicationsThe findings of this study have implications for nurse administrators, educators,professional nursing organizations and future research. These are discussed below.Nurse AdministratorsIt is clear that excellent communication skills are essential for the CNE position.This includes skill in written and verbal communication as well as expertise in publicrelations. Given the fact that CNEs are assuming a broader span of control and thatpositive person-person relations and group dynamics were seen to be integral to the role,being a skilled communicator is likely to be one of the keys to the success of a CNE.This finding has several implications for the CNE. First and foremost, those individualswho are not skilled communicators should not consider such a position. Second, it isessential that those selected to be CNEs are cognizant of their communication style and68should continually assess the effects of their communication style on others to determineits effectiveness. Lastly, because communication skills were deemed to be intergral to therole, CNEs should continually strive to refine their communication abilities.Many of the management functions ranked highly and, within this group,evaluation and planning methods and computer applications in health care were seen tobe of increasing importance. With the rapid and inevitable influx of computertechnologies into health care it would be prudent for CNEs to play a proactive role indetermining the specific managerial applications they require from this technology,otherwise vendors will design less than adequate applications for nursing. Conversely,labour relations and collective bargaining were seen to be of decreasing importance.While this would appear to continue to be an integral component of the CNEs' role,clarification on this point by the CNEs would assist in determining the most suitableformat for preparing future nurse administrators to manage labour relations issues. Forexample, in the future it may only be necessary for CNEs to have a broad understandingof the history and structure of specific labour unions as opposed to the details of aspecific collective agreement and the bargaining process.Nursing knowledge overall was ranked of relatively low importance by theCNEs. This finding has serious implications for the future of the nursing profession. Ata time when the health care system is being restructured, the nursing profession has anopportunity to define a new role and the value of its service to the public. With anunderstanding of nursing issues and areas requiring nursing research as well as nursingtheories the CNE can provide strong leadership in shaping the nursing organization tooperate more effectively within the changing health care system. Nursing theories, inparticular, can assist in clarifying the role, especially within the increasingly popular69multidisciplinary program management organizational structures. Furthermore, nursingtheories can be used in the selection of the most cost effective nursing interventions fora specific diagnostic related group (DRG). As the most senior nurse in the organization,the CNE can provide leadership in evaluating the effectiveness of nursing theories andutilizing them to demonstrate tangible outcomes.The CNEs appear to recognize the broader context of health care and thedirections of health care reform within the province. The high priority assigned tomanaging change now and in the future is perhaps a result of the provincial health carereform process. Although managing change is perceived as important, the role CNEs areplaying in terms of initiating changes to advance the position of nursing within theirorganizations is less apparent. Given their senior positions as well as their potentialpower as a group, these CNEs could play a key role in determining future directions forthe nursing profession at the community, provincial and national level consistent with thenew directions in health care. For example, it is important to develop programs whichemphasize health promotion and prevention and define and implement infrastructureswhich promote continuity of care between the hospital and community.Nurse Educators Several of the findings have implications for nurse educators responsible for theeducational preparation of future nurse administrators. One of the most striking findingsof this study was the fact that the majority of CNEs were prepared at the graduate levelbut most chose to obtain this education in disciplines other than nursing. Whether theseCNEs obtained any advanced nursing knowledge during the pursuit of their graduateeducation is not known. Nonetheless, if the nursing profession hopes to have its leadersprepared within nursing, nursing faculty who are designing curricula for nursing70administration programs should critically examine the content of their programs to ensurethey are consistent with practise expectations and provide flexibility in terms of theavailability of courses.The high rankings given to many of the management and health administrationknowledge and skills suggest that this content should definitely be included in theeducation of nurse administrators. The amount of emphasis that should be placed onadvanced nursing content is, however, less clear from these findings. Although nursingknowledge overall was ranked low, most CNEs stated that they used nursing knowledgea significant proportion of their time (up to 60%). Therefore the CNEs' nursingbackground is obviously of some benefit to them in managing the nursing organization.It is recommended, therefore, that the graduate preparation of nurse administrators occurwithin nursing with a strong emphasis on content from commerce and healthadministration. Also, as nursing faculty may not be prepared to teach this content,arrangements could be made with the other faculties to accommodate nursing students.Given the rapid and dramatic restructuring of the provincial health care system,nurse educators should consider providing flexible educational experiences for futurenurse administrators which incorporate the administration of nursing in a variety ofmilieus. For example, many of the traditional service-oriented acute care hospitals arenow focusing on multidisciplinary program management models, and others are focusingon out-patient services, day hospitals or ambulatory clinics. The nursing profession isalso proposing the development of independent health organizations such as nursingcenters. Given the development of these new structures and organizations, it is likelythat the nurse administrators of the future will be faced with new opportunities and adifferent set of challenges. Nursing programs preparing administrators should, therefore,71take into consideration the changes and provide educational experiences which prepareadministrators to manage the new organizations.Professional Nursing OrganizationsProfessional nursing organizations such as the Registered Nurses Association ofBritish Columbia (RNABC), the Nurse Administrators Association of British Columbia(NAABC), and the Canadian Nurses Association (CNA) can also play a role in ensuringthat CNEs are prepared to enact the role successfully. Although the CNA has articulateda role for the nurse administrator as well as standards for practice (CNA, 1988 ), thesehave not been revised since 1988. The fact that the health care system is changing andthat the CNA sets the standards for all nurse administrators indicates the need for areview of nursing administration practise with a move to identifying a specific set ofstandards reflective of a changing health care environment. Locally, organizations suchas the RNABC and the NAABC could recommend that the management education needsof practising CNEs are articulated as the role continues to evolve in the midst of healthcare reform and that continuing education initiatives are developed to assist CNEs to gainthe necessary knowledge and skills to manage organizations within the changing healthcare context.Future ResearchThe titles of the CNE positions indicate that they are assuming a broader spanof control within organizations. Exactly what the motivation is for this increase inresponsibility and what the extent of the responsibilities are is not apparent, however.Neither is the impact of these increased responsibilities on the effectiveness of the CNEand his/her relations with other departments and senior managers. Clarification of thesepoints through research would assist educators in providing appropriate learning72experiences for nurse administrator students thereby developing a stronger curriculum.The fact that a significant proportion of the CNEs in this study pursued graduateeducation in disciplines other than nursing is interesting. Further exploration of thisfinding is necessary to determine the CNEs' motivation for selecting a non-nursingdegree. Furthermore, clarification on this point is needed to determine the motivation forchoosing a non-nursing degree and whether a masters degree in nursing was evenconsidered as an option. Finally, it would be useful to determine which degree theseCNEs would recommend to prospective CNEs and under what circumstances would theymake that recommendation.Communication skills were consistently ranked highly but it is unclear if theCNEs perceived these skills to be especially difficult to master or if especiallysophisticated skills are required. Clarification on this point by the CNEs would be usefulin determining the most appropriate type and format for preparing incumbent as well asfuture CNEs to be skilled communicators. Similarly, it would be useful to clarify withCNEs the issues which dominate specific groups with whom they communicate, internaland external to the organization, in order to provide the appropriate educational supportto deal effectively with these groups.Although this study argued for the importance of obtaining the perspective ofpractising CNEs with respect to the knowledge and skills required for successfuladministrators, the value of the opinions of others should not be negated. As a meansof comparison, it would therefore be useful to survey other groups such as chiefexecutive officers, nurse leaders, nurse educators and professional nursing organizations(e.g., the RNABC) with respect to their opinions of the knowledge and skills requiredof CNEs.73The CNEs in this study included only those employed in acute care hospitals inBritish Columbia. Therefore, to confirm the findings in this study, it would be beneficialto conduct a comparative survey with CNEs employed in other health care sectors, suchas the community, as well as other provinces where the health care reform process maybe further advanced, for example, Ontario.Finally, it is recommended that the questionnaire be revised prior to further useto increase the utility of the data. For example, the obvious outlier skills should beremoved fron the questionnaire and the individual knowledge and skills re-organized intothe appropriate knowledge/skill groups, as necessary.The findings of this descriptive study (the most recent Canadian study since 1978)have demonstrated that the CNE's role requires knowledge from several disciplines. Thedata provide some understanding of the CNE's role within a changing health careenvironment; however confirmation, clarification and elaboration of the findings throughfuture research are needed in order that CNEs are prepared effectively for success intheir positions.74REFERENCESAlexander, J.A. (1988). The effects of patient care unit organization on nursing. HealthCare Management Review,13(2), 61-72.Arndt, C., & Huckabay, L. (1980). Nursing administration: Theory for practice withina systems approach. St. Louis: Mosby.Aydelotte, M.K. (1968). Survey of hospital nursing service. New York:National League for Nursing.Biordi, D.L. 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Journal of Nursing Education, 27(5), 210-218.APPENDIX AAssessment of Knowledge Areas and Skills Requiredby Chief Nurse Executives798(Assessment of Knowledge Areas andSkills Required by Chief Nurse ExecutivesUniversity of British ColumbiaJanuary, 19931.^Please list the full-time positions you have held (health related or otherwise), beginning with your present position.Type of Organization,Position Title^Institution or Association^ Dates(e.g. hospitaVlocal health unit)PresentlyHeld:PreviouslyHeld:PreviouslyHeld:PreviouslyHeld:PreviouslyHeld:From 19 to the Present 19 to 1919 to 1919 to 1919 to 192. Please indicate the total number of beds in the facility you are currently working in.Total # of beds3. Do you have ultimate administrative responsibility for any departments in addition to nursing. Yes^NoIf yes, please list.4. List below any degrees, diplomas, certificates or other educational or professional qualifications which you havecompleted (beginning with the most recent qualification obtained):Major Field^ Institution or AgencyQualification^Year Obtained^of Study Granting Qualification5. If you are actively working toward any other qualification indicate below:Qualification^Expected Date of^Major Field^Institution or AgencySought Qualification of Study Granting Qualification-2-^ 816.^Indicate your age group by circling the appropriate number below:Under 25 1 35 to 39 4 50 to 54 725 to 29 2 40 to 44 5 55 to 59 830 to 34 3 45 to 49 6 60 & over 97.^Sex: Male^ Female8.^This question asks about the kind of knowledge and skills which you consider important for successfulperformance, both now and in the future, for the type of position which you presently hold.Using the scale below and thinking of the knowledgeand skills required at the present time for successfulperformance in your job, please circle in Column A thelevel of importance of each of the following areas.In the light of changes you foresee in the next few yearsor already underway in the health care field, pleaseindicate in Column B how important each of the followingareas will be for successful performance in the type ofposition you presently hold in future years.Not^Moderately^VeryImportant Important Important1^2^3^4^5Column A(Circle) Management FunctionsColumn B(Circle)1 2 3 4 5 1. Preparation and analysis of budgets 1 2 3 4 51 2 3 4 5 2. Accounting principles and methods as applied to the health field. 1 2 3 4 51^2 3 4 5 3. Labour relations and collective bargaining 1 2 3 4 51 2 3 4 5 4. Personnel administration (including recruiting, appraisals, payschemes, and disciplining) 1 2 3 4 51 2 3 4 5 5. Problem solving and decision making methods 1 2 3 4 51 2 3 4 5 6. Purchasing principles and how to develop sound procurement policy 1 2 3 4 51 2 3 4 5 7. Management theories and methods 1 2 3 4 5Analytical Methods and Skills1 2 3 4 5 8. Basic statistical and quantitative methods 1 2 3 4 51^2 3 4 5 9. Basic understanding and interpretation of statistical data 1 2 3 4 51^2 3 4 5 10. Computer applications to health services 1 2 3 4 51^2 3 4 5 11. Evaluation methods (for example, of programs or quality of care) 1 2 3 4 51^2 3 4 5 12. Operations research and/or systems analysis 1 2 3 4 51 2 3 4 5 13. Health services planning methods 1 2 3 4 51 2 3 4 5 14. Epidemiology (methods of determining the incidence andpatterns of illness and health in specific groups) 1 2 3 4 5Health Services Knowledge1 2 3 4 5 15. Current epidemiological information (data describing the recentincidence and patterns of illness and health in specified groups) 1 2 3 4 51^2 3 4 5 16. Prevention and maintenance of health 1 2 3 4 51^2 3 4 5 17. Community and citizen involvement in health services 1 2 3 4 51 2 3 4 5 18. Government policy as it affects health services 1 2 3 4 51 2 3 4 5 19. Health services planning issues (such as regionalization andintegration of services) 1 2 3 4 51^2 3 4 5 20. The law as it relates to health services 1 2 3 4 51^2 3 4 5 21. Ethical and moral issues relating to health services 1 2 3 4 51^2 3 4 5 22. Health care trends in Canada 1 2 3 4 51 2 3 4 5 23. Health care trends in other countries 1 2 3 4 51 2 3 4 5 24. Relationships between health services and social policies and services 1 2 3 4 51 2 3 4 5 25. An overview of medical science and technology, includingmedical terminology 1 2 3 4 51 2 3 4 5 26. Ecological and environmental factors affecting health services 1 2 3 4 5Knowledge of the organization and operation of ...1 2 3 4 5 27. ...general acute hospitals 1 2 3 4 51 2 3 4 5 28. ...specialized hospitals, e.g., orthopedics, cancer 1 2 3 4 51^2 3 4 5 29. ...public health units and programs 1 2 3 4 51 2 3 4 5 30. ...mental health programs and facilities 1 2 3 4 51 2 3 4 5 31. ...ambulatory care programs 1 2 3 4 51^2 3 4 5 32. ...long-term facilities such as chronic hospitalsand nursing homes 1 2 3 4 51^2 3 4 5 33. ...rehabilitation programs and facilities 1 2 3 4 51^2 3 4 5 34. ...regional services (including health councils) 1 2 3 4 51^2 3 4 5 35. ...provincial and/or federal health services 1 2 3 4 5Communication Skills1^2 3 4 5 36. Written communication and report writing 1 2 3 4 51 2 3 4 5 37. Spoken communication, including talking, listening, and/orpublic speaking 1 2 3 4 51^2 3 4 5 38. Public relations 1 2 3 4 5Social Science Skills1^2 3 4 5 39. Economics as related to health and health services 1 2 3 4 51 2 3 4 5 40. Social and cultural aspects of health and illness,including patient and professional attitudes 1 2 3 4 51 2 3 4 5 41. Person to person relations and group dynamics 1 2 3 4 51^2 3 4 5 42. Effecting and managing change 1 2 3 4 51 2 3 4 5 43. Health promotion skills 1 2 3 4 5Nursing Knowledge1^2 3 4 5 44. Knowledge of nursing theories and their applicationsin administration and practice 1 2 3 4 51 2 3 4 5 45. Nursing research 1 2 3 4 51 2 3 4 5 46. Clinical expertise, advanced practitioner skills 1 2 3 4 51^2 3 4 5 47. Issues and trends in nursing 1 2 3 4 51^2 3 4 5 48. Nursing research utilization 1 2 3 4 5-4-^ 839. Although it is likely that you use multiple skills concurrently, please estimate how much time you spend using eachof the knowledge/skill groupings derived from the above list. Please circle only one time demand interval for eachknowledge/skill grouping. The overall total may exceed 100%.Knowledge/Skill Grouping^ Time DemandManagement Skills^0-20% 21-40% 41-60% 61-80% 81-100%Analytical Methods and Skills^0-20% 21-40% 41-60% 61-80% 81-100%Health Services Knowledge 0-20% 21-40% 41-60% 61-80% 81-100%Knowledge of the Organizationand its operation^0-20% 21-40% 41-60% 61-80% 81-100%Communication Skills 0-20% 21-40% 41-60% 61-80% 81-100%Social Science Skills^0-20% 21-40% 41-60% 61-80% 81-100%Nursing Knowledge 0-20% 21-40% 41-60% 61-80% 81-100%10. To prepare nurse executives of the future, based on your own experience and the knowledge and skills you perceiveimportant for successful performance in the type of position you presently hold, please circle the level of importance ofthe following educational courses.Not^Moderately^VeryImportant Important Important1^2^3^4^5one )2 3 4 5(CircleEducational Course 11. Health Care Management 1 2 3 4 52. Financial Management in Health Care 1 2 3 4 53. Managerial Accounting 1 2 3 4 54. Managerial Decision-Making 1 2 3 4 55. Personnel/Human Resource Administration 1 2 3 4 56. Management of Labor Relations 1 2 3 4 57. Statistics for Health Research 1 2 3 4 58. Health Information Services 1 2 3 4 59. Planning for Health Services 1 2 3 4 510. Epidemiology 1 2 3 4 511. Health Policy and Analysis 1 2 3 4 512. Canadian Health Services 1 2 3 4 513. Health Law 1 2 3 4 514. Socio-economic Factors and International Health Development 1 2 3 4 5-5- 8 415. Health Management Issues 1 2 3 4 516. Analysis of Health Care Organizations 1 2 3 4 517. Theory Development in Nursing 1 2 3 4 518. Critical Thinking in Nursing Practice 1 2 3 4 519. Nursing Research 1 2 3 4 520. Nursing and the Delivery of Health Care 1 2 3 4 5If you would like to make additional comments please do so in the space below.Thank you for taking the time to complete this questionnaire. Please return the questionnaire in the enclosed prepaidenvelope by^APPENDIX BCovering Letter85THE UNIVERSITY OF BRITISH COLUMBIA^86School of Nursing 3093 West 27th Ave,T. 206-2211 Wesbrook Mall Vancouver, BCVancouver, B.C. Canada V6T 2B5 V6L 1W6Fax: (604) 822-7466March 8th 1993Dear Chief Nurse Administrator:I am a student in the Master of Science in Nursing program (nursing administration major) at theUniversity of British Columbia. I would appreciate your participation in my thesis research, whichfocuses on determining perceived knowledge and skill requirements of senior hospital nurseexecutives for successful performance of their jobs. To date, few attempts have been made to askpracticing nurse executives what they need to know to be effective administrators. This informationwill be useful in guiding the educational preparation of future nurse executives and providingcontinuing education for those in such positions. One questionnaire has been mailed to the chiefnurse administrator of each acute care hospital in BC with 100 or more beds.Confidentiality will be maintained by coding participants' names so that your identity is known onlyto the researcher. Your name and any other identifying information will not be used in the studyor in any future publications of the findings. Data will be reported in aggregate form only. All rawdata will be destroyed upon completion of the study. It is assumed that you have given consent toparticipate in this research project if you return the questionnaire. You may choose to withdrawfrom the study at any time.The questionnaire should take no more than 30 minutes to complete. Your response is veryimportant. Please complete and return the attached questionnaire, in the enclosed, self-addressed,prepaid envelope.If you have any questions about the study or the questionnaire, please call me at 739-0141, or mythesis supervisor, Dr. Marilyn Willman, at 822-7748. If you would like a summary of the completedresearch, please enclose your business card with the completed questionnaire.Thank you for your time and participation.Sincerely,Sheetal Donaldson, RN, BSN, Master's studentAPPENDIX COntario Health AdministratorsSurvey Questionnaire87University (.f TorontoJune, '1975/. Please list the full-time positions you have held (health related or otherwise). beginning with your present positicin.Type of Organization.Institution or AssociationPosition Title^(e.g. hospital/local health unit)^DatesPresentlyHeld: From 19 to the PresentPreviouslyHeld: 19 to -^19PreviouslyHeld: 19 to 19PreviouslyHeld: 19 to 19PreviouslyHeld: 19 to 19PreviouslyHeld: 19 to 192. List below any degrees, diplomas, certificates or other educational or professional qualifications which you have completed(beginning with the most recent qualification obtained):Major FieldQualification^Year Obtained^of StudyInstitution or AgencyGranting Qualification3. If you are actively working toward any other qualification indicate below:Qualification^Expected Date of^Major FieldSought Qualification of StudyInstitution or AgencyGranting Qualification4. Please indicate your present annual salary (circle the appropriate number below):510.000 and under 1 525.000 to 529.999 - 5530,000 to 539,999 6510,001 to 514,9993 $40,000 and over 7515.000 to 519,999520,000 to S24.999 ------------ 4-L5. On the average. approximately how man} hours do you work per week in your present position?^Hours6. Indicate your age group by circling the appropriate number below:Under 1 35 to 39 4 50 to 54 -------^725'5^li)to, 2 40^44to 5 55 to 59 ----------- R30 to 34 ---------- 3 45 to 49 -- 6 60 and over — — 988Female47- Sex^Malely hold,in future years.Not^ Moderately^ VeryImportant Important Important3^4^5MANAGEMENT FUNCTIONS Column B(Circle)5 I. Preparation and analysis of budgets I^2 3^4 55 2. Accounting principles and methods as applied to the health field 1^2 3^4 55 3. Labour relations and collective bargaining 1^2 3^4 55 4. Personnel administration (including recruiting, appraisals, pay schemes,and disciplining)1^2 3^4 55 5. Problem solving and decision making methods 1^2 3^4 55 6. Purchasing principles and how to develop sound procurement policy 1^2 3^4 55 7. Management theories and methods I^2 3^4 5ANALYTICAL METHODS AND SKILLS5 8. Basic statistics and quantitative methods I^2 3^4 55 9. Epidemiology ( incidence and pattern of illness and health) 1^2 3^4 5S^10. Computer applicatims to I►esdtb services - - -^- -15 --S I I. Evaluation methods (for example, of programs or of quality of care) 1^2 3^4 55 12. Operations research and systems analysis 1^2 3^4 5HEALTH SERVICES5 13. Health promotion, prevention, and maintenance 1^2 3^4 55 14. Community and citizen involvement in health services 1^2 3^4 55 15. Government policy as it affects health services 1^2 3^4 55 16. Health services planning (including such issues as regionalization andintegration of services)1^2 3^4 55 17. The law as it relates to health services 1^2 3^4 55 18. Health care trends in Canada 51^2 3^45 19. Health care trends in other countries I^2 3^4 55 20. Relationships between health services and social policies and services I^2 3^4 55 21. An overview of medical science and technology, including medicalterminologyI^2 3^4 522. Organization and operation of:5 hospitals -- I>^1^2 3^4 5<------ -^) general acute5 4--^- (ii I specialized hospitals, e.g.irthopaedic, cancer - >^1^2 3^4 55 1161^health units and - programs^--public^ - > 1^2 3^4 55 (ivl mental health^and facilities----- programs^ - — >^i^2 3^4 55 v) ambulatory care -<- —^ programs - I^2 3^4 55 (vii long-term care facilities such as chronic hospitals andnursing homes--- >^I^2 3^4 55 a-----^(vut rehabilitation programs and facilities - •---^- - >^1^2^3 4 55 I %oil) regional services (including health councils)<- 1^2^3 4 55 (ix)^and/or federal health services<^ provincial 1 2^3 4 55 23. Ecological and environmental factors affecting health services 1^2^3 4 5Column A(Circle)I 2 3 41 2 3 41 2 3 41 2 3 41 2 3 41 2 3 41 2 3 42 3 4.^1 2 3 42 3 41 2 3 43 41 2 3 41 2 3 4I 2 3 41 2 3 41 2 3 41 2 3 41 2 3 41 2 3 41: 2 3 41 2 3 4I 2 3 _41 2 3 4I 2 3 41 2 3 4I 2 1 .4I 2 3 41 2 3 41 2 3 41 2 3 4This question asks about the kind of knowledge and skills which you consider important for successful performance, both^89now and in the future,fOr the type of position which you presently hold.Using the scale below and thinking of the knowledge andskills required at the present time for successful performancein your job, please circle in Column A the level of importanceof each of the following areas.In the light of changes you forsee in the next few years oralready underway in the health care field, please indicate inColumn B how important each of the following areas will befor successful performance in the type of position you present-COMMUNICATIONI^2^3^4^5^24. Written communication and report writing^ I^2^3^4I^2^3^4^5^25. Oral communication and public speaking 1^2^3^41^2^3^4^5^26. Public relations^ 1^2^3^4THE SOCIAL SCIENCE AREAS1^2^3^4^5^27. Economics as related to health and health services^ I^2^3^41^2^3^4^5^28. Social and cultural aspects of health and illness, including patient and^1^2^3^4professional attitudes1^2^3^4^5^29. Interpersonal relations and group dynamics^ 1^2^3^4There may be some knowledge and skill areas which are omitted from the above list and which you feel are, or will he,important for the successful performance of your present position. Please list these below and circle to indicate the level ofimportance you attach to these areas both now and in the future.I^2^3^4^5 1^2^3^45555555901^2^3^4^5 I^2^3^4• •se health care field evolves, it becomes increasingly difficult to keep abreast of changes that have or are occuring. Oneto do this is through the medium of continuing education. The next question deals with continuing education programs.. Each of the subject areas in Question 8 above is numbered: if you would be interestidlirliking courses in anyatilet-Cireas;--pleur---list the appropriate number in the column below. Up to four subjects may be listed. Then, please indicate, by checking theappropriate box, which format you prefer for each subject you have listed.FORMAT-SUBJECT AREANUMBER(In descending orderof preference)4* 4^y"0^oc^t-.^••,.7c^,- c^ ,2?-, pir,"4 o,^4, ..„c ...4 ^0 -C Z..... --- Z. Z.-4 ." . . ." - , . .0 o^Other format preferred,... 4.- c E`' I? g --. (Please specify).47a '-' ft-- c 4 .t-....., g.ti , i.,(First choice)••___9b. Do you feel that continuing education courses should count for credit at post secondary institutions? (check one)--- yes— — no-- no preferenceQuestionnaire Continues OverleafmgJsing the scale below, please fill in the blanks to the left of eacii statement to indicate the approximate amount of time youtypically spend during the year in carrying out each of the ace ties listed.Time Scalealmostnone little moderate much^all0^1^2^3^4^ Planning goal, policies, and courses of action^ Planning new programs, example: an accident prevention program^ Preparing financial statements or budgets^ Analysing financial statements or budgets^ Planning or coordinating physical expansion or renovation^ Fund raising^ Analysing information such as reports, statistics and records^ Carrying out, coordinating or supervising research projects^ Epidemiological investigation^ Investigating and resolving complaints or problems^ Attending meetings within your organization^ Liaison with government agencies, example: the Ministry of Health, local or regional government^ Liaison with organizations other than government agencies^ Liaison with governing bodies; exampler -Doerd-of-Governors-or-Trustees_^ Explanation or enforcement of rules, by-laws, statutes, etc.^ Evaluating your organization's overall performance^ Evaluating departmental or program performance^ Assessment and appraisal of proposals and requests^ Directing and/or advising subordinates^ Relating to professionals within your organization but not directly under your administrative control, example: non-salaried M.D.'s in a hospital^ Appraisal, promoting, transfering or dismissing employees^ Wage and salary administration^ Collective bargaining with professional associations and/or unionsActive participation in teaching on a regular basis at an educational institution^ Advancing general organizational interests through speeches, consultation, contacts with individuals or groups, etc.^ Meetings with or having discussion with clients, patients or their relativesDealing with legal issues or problems.attending professional conferences, meetings or workshopsUsing clinical expertise such as medicine or nursing in your work, example: running a V. D. clinicPrivate practice of a clinical professionThere may he some aspects of your present Job functions which we have omitted in the list above. II so, please indicate thesebelow.I91Thank you for completing this questionaire (Please return the questionaire in the enclosed prepaid envelope).APPENDIX DCanadian Health AdministratorsSurvey Questionnaire92Etude relative aux administrateurs de b Sante au Canada^93Canadian Health Administrator Study^ersity of Toronto. Faculty of Medicine. Department of Health Administration, Fitzgerald Building. Toronto, Ontario M5S 1A1.NOVEMBER 1977Si vous prèfirez recevoir la version francaise de ce questionnaire, veuillez l'indiquer ( V ) dans la caseappropriie et retourner ce questionnaire dans l'enveloppe affranchie. 01. Please list the full-time positions you have held (health related or otherwise), beginning with your present position. ^Name of Organization,^ YearsPosition Title^Institution or Association Province^From^To 19 ^Present19 ^19 19 ^19 19 ^19 ^ 19^19 19^19PRESENTPOSITION:PreviouslyHeld:PreviouslyHeld:PreviouslyHeld:PreviouslyHeld PreviouslyHeld:2. List below any degrees, diplomas, certificates or other educational or professional qualifications which you have received (begin-ning with the most recent qualification obtained). If you have not received any such qualifications, please check (V) this box: 0Institution or AgencyQualification^Year Obtained^Major Field of Study^Granting Qualification3. If you are now actively working toward any qualifications, please list below:Expected Date of^ Institution or AgencyQualification Sought^Qualification Major Field of Study^Granting Qualification4. Have you ever had any additional administrative training that did not result in a degree, diploma, certificate or other educationalor professional qualification (for example, military officer training)? Indicate below.Description or Title of Training^Year of Training^Institution or Agency Giving Training5. Please indicate your present gross annual salary by circling the appropriate number to the right of the salary groups:Less than $10,000^ 1^$35,000 to $39,999^  7$10,000 to $14,999 2 $40,000 to $44,999  8$15,000 to $19,999 3^$45,000 to $49,999  9$20,000 to $24,999 4 $50,000 to $54,999 10$25,000 to $29,999^ 5^$55,000 to $59,999^ 11$30,000 to $34,999 6 $60,000 and over 126. Age-^ (years)7. Sex: ['Male UFemale948. This question asks about the kind of knowledge and skills which you consider important for successful performance, both nowand in the future, for the type of position which you presently holdUsing the scale below and thinking of the knowledgeand skills required at the present time for successfulperformance in your job, please circle in Column A thelevel of importance of each of the following areas.In the light of changes you forsee in the next ten years or alreadyunderway in the health care field, please indicate in Column B howimportant each of the following areas will be for successful perfor-mance in the type of position you presently hold in future years.Column A(Circle)Not^ Moderately^ VeryImportant Important Important1 2^3 4^5Column B(Circle)MANAGEMENT SKILLS1^2 3^4 5 I. Preparation and analysis of budgets 1 2 3^4^51^2 3^4 5 2. Accounting principles and methods as applied to the health field 1 2 3^4^51^2 3^4 5 3. Labour relations and collective bargaining 1 2 3^4^51^2 3^4 5 4. Personnel administration (including recruiting, appraisals, pay schemes, anddisciplining)1 2 3^4^51^2 3^4 5 5. Problem solving and decision making methods 1 2 3^4^51^2 3^4 5 6. Purchasing principles and how to develop sound procurement policy 1 2 3^4^51^2 3^4 5 7. Management theories and methods 1 2 3^4^5ANALYTICAL METHODS AND SKILLS1^2 3^4 5 8. Basic statistical and quantitative methods 1 2 3^4^51^2 3^4 5 9. Basic understanding and interpretation of statistical data 1 2 3^4^51^2 3^4 5 10. Computer applications to health services 1 2 3^4^51^2 3^4 5 11. Evaluation methods (for example, of programs or of quality of care) 1 2 3^4^51^2 3^4 5 12. Operations research and/or systems analysis 1 2 3^4^51^2 3^4 5 13. Health services planning methods 1 2 3^4^51^2 3^4 5 14. Epidemiology (methods of determining the incidence and patterns of illnessand health in specific groups)1 2 3^4^5HEALTH SERVICES KNOWLEDGE1^2 3^4 5 15. Current epidemiological information (data describing the recent incidenceand patterns of illness and health in specified groups)1 2 3^4^51^2 3^4 5 16. Prevention and maintenance of health 1 2 3^4^51^2 3^4 5 17. Community and citizen involvement in health services 1 2 3^4^51^2 3^4 5 18. Government policy as it affects health services 1 2 3^4^51^2 3^4 5 19. Health services planning issues (such as regionalization and integration of services) 1 2 3^4^51^2 3^4 5 20. The law as it relates to health services 1 2 3^4^5I^2 3^4 5 21. Ethical and moral issues relating to health services 1 2 3^4^51^2 3^4 5 22. Health care trends in Canada 1 2 3^4^51^2 3^4 5 23. Health care trends in other countries 1 2 3^4^51^2 3^4 5 24. Relationships between health services and social policies and services 1 2 3^4^51^2 3^4 5 25. An overview of medical science and technology, including medical terminology 1 2 3^4^51^2 3^4 5 26. Ecological and environmental factors affecting health services 1 2 3^4^5KNOWLEDGE OF the organization and operation of ...1^2 3^4 5 27 ... general acute hospitals 1 2 3^4^51^2 3^4 5 28 ... specialized hospitals, e.g. orthopaedic, cancer 1 2 3^4^51^2 3^4 5 29 ... public health units and programs 1 2 3^4^5I^2 3^4 5 30 ... mental health programs and facilities 1 2 3^4^51^2 3^4 5 31 ... ambulatory care programs 1 2 3^4^51^2 3^4 5 32 ... long-term facilities such as chronic hospitals and nursing homes 1 2 3^4^51^2 3^4 5 33 ... rehabilitation programs and facilities 1 2 3^4^51^2 3^4 5 34 ... regional services (including health councils) 1 2 3^4^51^2 3^4 5 35 .^provincial and/or federal health services 1 2 3^4^5COMMUNICATION SKILLS1^2 3^4 5 36. Written communication and report writing 1 2 3^4^51^2 3^4 5 37. Spoken communication including talking, listening, and/or public speaking 1 2 3^4^51^2 3^4 5 38.^Public relations 1 2 3^4^5CI^ ^ ^El ^ El ^D ^[i]SUBJECT AREA NUMBERFROM QUESTION 8 (indecending order of preference)1st choice2nd choice3rd choice4th choicexs).44i Z-`)'" A,1/40 NC> N>^ va o`O^tamSe■I'Cc■° 0 • 44\S‘' 0S1'^NIst,x2.5^4 )'^%•■•Other Format Preferred(Please Specify)95SOCIAL SCIENCE SKILLS1^2 3 4 5 39. Economics as related to health and health services 1 2 3 4 51^2 3 4 5 40. Social and cultural aspects of health and illness, including patientand professional attitudes1 2 3 4 51^2 3 4 5 41. Person to person relations and group dynamics 1 2 3 4 51^2 3 4 5 42. Effecting and managing change 1 2 3 4 51^2 3 4 5 43. Health promotion skills 1 2 3 4 5There may be some knowledge and skill areas which are omitted from the above list and which you feel are, or will be, important forthe successful performance of your present position. Please list these below and circle to indicate the level of importance you attachto these areas both now and in the future.1^2 3 4 5 44 1 2 3 4^545 11^2 3 4 5 2 3 4^546 ^ 11^2 3 4 5 2 3 4^5As the health care field evolves, it becomes increasingly difficult to keep abreast of changes that have or are occuring. One way to dothis is through continuing education. The next set of questions deals with continuing education programs.9a. Each of the subject areas in Question 8 above is numbered. If you would be interested in taking courses in any of these knowledgeand skill areas, and they were available to you, please list the appropriate number from question 8 in the column below. Then,please indicate, by checking (y') the appropriate box, which format you prefer for each subject you have listed.COURSE FORMAT9b. There are many ways an administrator can continue to update his or her professional education in health administration. Whichof the following methods of continuing education do you feel are most valuable? Please rank your choices in the boxes below,beginning with number one (I) as the most valuable and omitting any that you feel have no value at all.O a. Professional and trade journals^E e. Conversations with colleaguesO b. Conferences sponsored by health related associations 0 f. Commercial management consultant sponsored programs0 c. Conferences sponsored by other associations^g. Professional association offices, committee work, task forcesO d. University/community college sponsored programs^h. Other (specify) ^9c. Who should conduct continuing education in health administration? Again, please rank your choices, in the boxes below, beginningwith number one (1) being the most responsible for the conducting of programs.0 a. Professional associationsR b. Universitiesc. Community collegesd. Governmente. Other (specify) ^9d. How many formal continuing education programs (i.e., at least one day long) involving a group other than the agency by whichyou are employed, have you participated in during the past 12 months?^programs.9e. How many formal continuing education programs that were conducted by your employing agency have you participated in duringthe past 12 months?^programs.Questionnaire Continues Overleaf -■TIME SCALENone^Little0 1VeryModerate Much Much2^3^41.2.3.4.5.6.1.2.3.1.2.3.■-■•■■■■■•■1O .Are you a full-time administrator in your present position?^YES D^NO 0^ 96If you answered NO to this question, please indicate approximately what percentage of your time is devoted to administrativework in this position9^10b.We are interested in knowing how much you rely on the following selected skills to accomplish your job.In COLUMN A indicate the approximate amount of time onthe average per week you typically rely on the specific sub-skills(indicated by small letters) in each principal skill category(in capital letters), with respect to that category only, accordingto the scale below.COLUMN AIn COLUMN B indicate the approximate percentage oftime you rely on the principal skill categories (INCAPITAL LETTERS) in the course of your administrativework. The total percentage in Column B should equal100% of your administrative time.PERCENTAGECOLUMN BI. SPOKEN COMMUNICATION^ 1.1. individually with other health professionals2. individually with peers3. individually with subordinates4. with groups; at meetings5. public speaking6. listeningII. WRITTEN COMMUNICATION^ II.1. reports2. letters3. briefs and memosIII. READING/STUDY/ANALYSIS^ III.1. technical reports, journals2. mail3. analysis of information such as utilization data or financial recordsIV. THINKING, PONDERING, REFLECTING^ IV.V. OTHERS (SPECIFY) ^V.VL  VI.VII.  ^VII.%I% II1.^%,%1I^%I TOTAL = 100%11. What have been your greatest frustrations, difficulties or problem areas as an administrator in your present position? List up tothree below:1 ^2 3 ^12. We would welcome any further comments you would like to make. Please feel free to attach additional pages if necessary. (Beassured that any information provided by respondents in this survey will be treated with the strictest confidence).If you wish to receive a summary of the results of the survey, please check (1/) this box. 0.. • _^ roturn the nuestionnaire in the enclosed prepaid envelope.APPENDIX ECurrent Knowledge/SkillsRaw Scores97Knowledge/Skills Assessment-Current1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Individual Question MeanI. Communication SkillsQ.36-38 Individual Question Mean36 5 4 5 5 5 5 5 5 5 5 4 5 4 4 5 5 5 5 5 4.7937 5 4 5 5 5 3 5 5 5 5 4 5 3 5 5 5 5 5 5 4.6838 5 5 5 5 5 4 5 5 5 5 4 4 4 4 5 5 5 5 5 4.74Group Mean 4.74II. Social Science SkillsQ.39-43 Individual Question Mean39 3 4 5 4 3 3 3 4 5 5 3 4 4 2 4 4 4 4 5 3.8440 3 4 5 4 4 3 3 4 5 5 3 4 4 4 4 4 4 5 5 4.0541 3 4 5 5 5 4 5 5 5 5 4 5 5 5 4 5 5 5 5 4.6842 4 4 5 5 5 4 5 5 5 5 4 5 5 5 5 5 5 5 5 4.7943 3 4 5 3 3 3 3 4 4 3 3 3 3 2 2 4 4 4 5 3.42Group Mean 4.16DI. Management FunctionsQ.1-71 5 3 5 5 5 4 5 5 5 5 4 5 5 3 4 5 5 5 5 4.632 4 2 4 5 4 3 3 5 4 5 4 3 4 2 3 2 3 3 3.503 5 3 5 5 4 4 3 4 4 5 4 5 5 5 5 5 4 5 5 4.474 5 3 5 4 4 3 3 4 4 5 4 5 4 5 4 5 4 5 5 4.265 5 5 5 5 5 5 5 5 5 5 4 5 5 5 5 5 5 5 5 4.956 2 3 4 2 2 2 3 2 3 3 2 3 3 3 2 1 1 5 3 2.587 3 4 4 4 4 5 5 5 5 5 3 4 4 5 3 2 5 5 5 4.21Group Mean 4.09IV. Knowledge of the Organization Individual Question MeanQ.27-3527 4 5 5 4 5 4 4 5 5 5 4 5 4 4 5 5 5 5 5 4.6328 3 3 5 4 2 1 4 5 4 2 2 3 3 2 3 5 1 2 4 3.0529 3 3 5 4 3 2 4 4 4 4 2 4 3 2 3 4 3 3 4 3.3730 3 3 4 4 3 4 3 4 4 5 2 4 3 2 4 5 5 5 5 3.7931 3 3 5 4 5 4 4 5 4 5 3 4 3 2 5 5 5 5 5 4.1632 2 5 4 4 3 3 4 4 4 5 2 5 2 4 4 5 3 5 5 3.8433 2 4 4 4 3 3 5 4 4 2 4 2 3 4 5 3 4 5 3.6134 3 5 4 3 4 3 5 4 5 2 4 3 3 5 5 3 3 4 3.7835 2 5 4 3 2 3 5 4 5 3 5 3 3 4 5 3 3 4 3.67Group Mean 3.771 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20V. Nursing KnowledgeQ.44-48 Individual Question Mean44 4 5 4 4 5 2 5 5 5 4 3 5 3 4 4 4 5 5 5 4.2645 4 5 5 4 4 3 4 3 5 3 3 5 3 2 3 4 4 4 4 3.7946 3 3 4 5 2 2 2 2 5 2 1 3 3 3 1 3 5 3 4 2.9547 4 5 5 5 3 3 5 4 5 4 3 5 3 4 3 5 3 5 5 4.1648 3 5 5 3 3 3 5 3 5 3 2 5 3 3 2 5 4 4 4 3.68Group Mean 3.77VI. Analytical Methods and SkillsQ.8-14 Individual Question Mean8 3 3 4 3 3 4 3 4 3 4 4 3 2 2 3 3 4 4 3 3.269 4 4 5 4 3 4 4 5 4 5 4 5 2 3 4 3 4 4 5 4.0010 3 3 5 3 3 3 3 5 3 4 4 4 3 3 4 5 3 3 3 3.5311 4 4 5 5 4 5 3 5 3 4 3 5 2 3 5 5 5 5 3 4.1112 3 4 5 5 3 5 3 5 4 4 4 3 2 2 4 3 4 5 3 3.7413 3 3 5 5 3 4 3 5 4 5 3 4 2 3 4 5 4 5 3 3.8414 3 3 4 2 3 2 2 2 3 2 2 4 2 2 1 2 4 3 3 2.58Group Mean 3.58VII. Health Services KnowledgeQ.15-26 Individual Question Mean15 3 4 4 2 3 3 3 2 3 2 2 4 2 3 2 3 4 3 1 2.7916 3 4 5 3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3.1117 2 4 5 4 3 5 3 4 4 4 3 4 2 3 4 5 3 3 3 3.5818 3 4 5 4 3 4 4 5 5 5 4 5 4 4 5 5 5 5 5 4.4219 3 4 5 5 4 4 4 5 5 4 3 5 3 2 5 5 5 5 5 4.2620 4 4 4 3 3 3. 3 4 4 3 4 5 4 4 4 5 4 5 5 3.9521 4 5 5 4 4 4 4 5 4 5 3 5 2 3 4 5 4 5 5 4.2122 3 5 5 4 4 4 4 4 4 4 3 4 3 4 4 4 3 4 5 3.9523 2 4 4 3 3 3 2 3 3 4 3 3 3 3 2 3 1 3 3 2.8924 2 4 4 4 3 3 3 3 4 4 3 4 3 3 4 4 3 5 3 3.4725 3 4 3 3 1 2 4 3 5 4 4 3 3 3 5 1 3 3 3.1726 3 4 4 3 4 2 2 3 4 3 3 3 3 3 4 4 1 4 3 3.16Group Mean 3.58Mean (+/- SD) = 3.84 (+/-0.6) Median= 3.77 Range 2.58-4.95APPENDIX FFuture Knowledge/SkillsRaw Scores1000 Knowledge/Skills Assessment-Future1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20I. Communication SkillsQ.36-38 Individual Question Mean36 5 4 5 5 5 5 5 5 5 5 5 4 5 4 4 5 5 5 5 5 4.8037 5 5 5 5 5 5 5 5 5 5 5 5 5 4 5 5 5 5 5 5 4.9538 5 5 5 5 5 5 4 5 5 5 5 4 4 4 4 5 5 5 5 5 4.75Group Mean 4.83II. Social Science SkillsQ.39-43 Individual Question Mean39 5 5 5 4 4 4 3 4 5 5 5 3 4 5 3 5 5 5 5 5 4.4540 5 5 5 5 4 4 4 4 5 5 5 4 4 5 4 5 5 4 5 5 4.6041 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5.0042 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5.0043 4 4 5 4 3 4 2 4 5 5 3 4 3 4 3 3 5 4 5 5 3.95Group Mean 4.60I.Management FunctionsQ.1-7 Individual Mean1 5 5 5 5 5 3 5 5 5 5 5 4 5 3 5 4 5 5 5 5 4.702 5 4 4 3 4 3 3 3 5 4 5 4 3 3 4 3 4 2 4 3 3.653 5 4 5 4 4 3 3 3 5 4 5 5 5 2 5 5 5 4 5 5 4.304 5 3 4 4 4 3 4 3 5 4 5 5 5 2 4 3 5 4 5 5 4.105 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5.006 2 3 4 2 2 2 2 3 4 3 3 2 3 2 4 1 1 1 5 3 2.607 3 5 5 5 5 5 4 5 5 5 5 4 4 4 5 3 4 5 5 5 4.55Group Mean 4.12IV. Knowledge of the OrganizationQ.27-35 Individual Question Mean27 5 5 5 3 5 5 5 4 5 5 5 4 5 4 4 5 5 5 5 5 4.7028 3 3 5 3 2 2 3 4 5 5 2 3 3 3 2 4 5 1 4 5 3.3529 3 5 5 5 4 4 3 4 5 5 4 4 4 4 3 5 5 3 5 5 4.2530 4 5 5 5 4 4 3 4 5 5 5 4 4 4 3 5 5 5 5 5 4.4531 5 5 5 5 5 5 4 5 5 5 5 4 4 4 4 5 5 5 5 5 4.7532 5 5 4 4 3 2 4 4 5 5 5 4 5 3 4 5 5 3 5 5 4.2533 3 4 4 4 2 2 4 5 5 4 3 4 4 3 5 5 3 5 5 3.8934 3 5 5 5 5 3 5 5 5 5 4 5 4 4 5 5 3 5 5 4.5335 3 5 4 4 2 3 5 5 5 5 3 5 4 3 4 5 3 4 5 4.05Group Mean 4.25, ._1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20V. Nursing KnowledgeQ.44-48 Individual Question Mean44 3 5 5 4 4 4 5 5 4 5 4 3 5 5 4 3 3 5 5 5 4.3045 5 5 5 4 4 4 3 5 4 5 3 4 5 5 2 3 3 4 5 4 4.1046 2 3 4 3 2 4 3 2 2 5 2 1 3 5 3 1 3 5 3 4 3.0047 5 5 5 4 4 4 4 5 4 5 4 4 5 4 4 2 4 3 5 5 4.2548 4 5 5 5 4 4 3 5 3 5 3 2 5 5 3 3 5 4 5 4 4.10Group Mean 3.95VI. Analytical Methods and SkillsQ.8-14 Individual Question Mean8 4 3 4 3 4 3 4 3 4 3 4 4 3 4 3 3 3 4 5 4 3.609 4 5 5 4 4 3 4 5 5 4 5 4 5 4 3 5 5 4 5 5 4.4010 5 5 5 4 4 3 5 4 5 3 4 4 5 4 4 5 5 3 5 5 4.3511 5 4 5 5 5 4 5 5 5 3 5 4 5 5 4 5 5 5 5 5 4.7012 4 4 5 5 3 4 2 4 5 4 4 4 3 4 3 5 4 5 5 5 4.1013 4 5 5 5 4 4 4 4 5 4 5 4 4 4 5 5 4 5 5 5 4.5014 4 3 5 2 4 4 2 2 5 3 2 3 4 5 4 2 3 5 3 5 3.50Group Mean 4.16VII. Health Services KnowledgeQ.15-26 Individual Group Mean15 4 4 4 2 4 4 2 3 3 4 2 3 4 5 4 3 3 4 3 1 3.3016 5 5 5 3 4 4 3 4 4 4 3 4 3 4 3 3 3 4 5 5 3.9017 4 4 5 4 4 5 4 4 5 4 5 5 5 5 4 5 5 4 5 5 4.5518 5 5 5 5 4 5 5 4 5 5 5 4 5 3 4 5 5 5 5 5 4.7019 5 5 5 5 5 5 5 4 5 5 5 4 5 5 4 5 5 5 5 5 4.8520 5 4 4 3 4 5 5 3 4 4 3 4 5 4 4 4 5 4 5 5 4.2021 5 5 5 4 5 5 5 4 5 4 5 4 5 5 4 5 5 5 5 4.7422 3 5 5 4 5 4 4 4 5 4 4 3 4 3 4 5 4 5 5 4.2123 3 4 5 4 4 4 3 3 4 3 4 3 3 3 3 3 4 1 4 4 3.4524 4 5 5 4 4 4 3 4 5 4 5 3 4 5 4 4 3 3 5 5 4.1525 3 4 3 3 1 3 2 4 3 5 4 4 3 3 3 4 1 4 4 3.2126 4 4 5 4 4 3 2 3 4 4 4 4 3 4 3 4 4 1 5 4 3.65Group Mean 4.08Mean (+/-SD)=3.87 (+/-0.6) Median=4.12 Range 2.60-5 00APPENDIX GCourses and Corresponding Disciplines103Courses and Corresponding Disciplines104COURSEHealth Care ManagementFinancial Management in Health CareManagement AccountingManagerial Decision MakingPersonnel/Human AdministrationManagement of Labour RelationsStatistics for Health ResearchHealth Information SystemsPlanning for Health ServicesEpidemiologyHealth Policy and AnalysisCanadian Health ServicesHealth LawSocio-Economic Factors and InternationalHealth DevelopmentHealth Management IssuesAnalysis of Health Care OrganizationsTheory Development in NursingCritical Thinking in Nursing PracticeNursing ResearchNursing and the Delivery of Health CareDISCIPLINEHealth Care and Epidemiology (HCEP)HCEPMaster of Business Administration (MBA)MBAMBAMBAHCEPHCEPHCEPHCEPHCEPHCEPHCEPHCEPHCEPHCEPMaster of Science in Nursing (MSN)MSNMSNMSN

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