Data analysis led to the extraction of over one hundred initial codes. After merging the codes, omitting the overlapped ones and categorizing them, 21 categories and four main themes were obtained. Data analysis showed that the head nurses of the intensive care unit had four kinds of educational needs for acquiring managerial competence, which were the same themes as that proposed by the researchers. All of the themes overlapped with each other to some extent. As illustrated by
Figure 1, these needs included, “scientific needs”, “artistic needs”, technical needs”, and “organizational needs”.
Figure 1. The Main Themes of Educational Needs of Head Nurses at Intensive Care Units
4.1. Academic Needs
The categories, which resulted in the formation of this theme, were actually related to scientific concepts required by the head nurses of intensive care units. These categories included the need for managing knowledge, the need for knowledge and skills in scientific research, the need for acquiring knowledge about intensive clinical care, the need for acquiring the knowledge on teaching and learning principles, and the need for acquiring knowledge and skills for new methods of care.
The participants stated that one of their educational needs for gaining managerial competence was acquiring management knowledge in the fields of strategic management, process and change management, participatory decision making, team management, unit organizing, strict monitoring, planning, and managing knowledge and crisis. For instance the participants expressed their experience in this way:
“When I was a head nurse, I did not take these courses (management courses) at all. Like other people or like most of them, I used to think that management is something inborn. But, now that I have participated in some of classes, I have realized that if I had this knowledge (management knowledge), I would have performed better” P1.
Participant number 10 talked about an experience that was representative of the head nurses’ need for awareness of management knowledge. “Ms. A was an auxiliary nurse who had retired, based on her experience; during her role as a head nurse she would give soft food rather than liquids to the patients for whom the endotracheal tube was removed and they started to eat food and it was interesting that the patients would tolerate it. Recently, one of the trainers said that she/he has read this matter in an article. Such experiences were lost when Ms. A retired” P 10.
Regarding the planning and organizing forces, a great deal of experience was retrieved including the following:
“Today in bed number 1, there was a pre-eclampsia patient and in bed number 3 there was a patient with diabetic ketoacidosis (DKA), so, I assigned them to a more potent nurse, while in bed number 11, there was an intubated patient, so I assigned him to a less potent nurse. Thus, the functions are shared among the personnel according to their capability and also the patients’ needs” P5.
One of the other educational needs on which the participants emphasized was the need for knowledge and skills for scientific research and valid recourses. For example, a participant stated, “we have graduated long ago. Now, thanks to the resources on the internet our gap in knowledge could be over come yet we must be able to have access to such resources, for example, about the difference in opinion about wound care; to cover it or to uncover it?” P8.
Also, they expressed their need to become familiar with research methodology; for instance, one of the participants said “what a large number of patients and works at the unit that can be studied. But when I wanted to start I found that I could not. I neither had the time nor the ability.” P3.
The participants believed that a competent head nurse must be firstly a good nurse at the intensive care unit. Therefore, she/he must have sufficient knowledge about the clinical care conducted at the intensive care unit. They thought of basic nursing knowledge, scientific care based on the nursing process, knowledge for study and recognition, knowledge for treating diseases and knowledge for intensive nursing, as necessities for a head nurse. Some of the retrieved quotations were as follows:
“When you don’t know what an under-ventilator patient needs, when you don’t know the device and its application, how can you control if this personnel is functioning properly or not?” P3.
These participants believed that a head nurse must have capabilities in training the staff, patients and students, and achieving this capability necessitates training, educational principles of mentoring, educational needs assessment. The following quotations are in this regard:
“When there is a new staff, I should start to teach all the required information to him/her. When I am less busy, I control all the staff in terms of their knowledge and performance. I provide them with educational programs and discussions” P1.
The participants stated that a head nurse must be able to understand and create an appropriate educational situation. “In the early morning at the time of shift changes there is a patient who has a fever. This is the best occasion to teach the personnel on how to deal with a patient with fever” P3.
In regards to the need for assessment of education, one of the participants stated, “at the audit time of the unit, the head nurse tells the nurse assistants what the problem of that unit is, for example the way of report writing, the way of wound dressing, etc. Then the head nurse holds or suggests a training program for the personnel” P9.
In addition, the participants mentioned some new requirements in the field of spiritual care and evidence-based care, which are new topics in patient care. “A head nurse can make the students get closer to the spirit of God with his/her doings like praying even when they are by the patients” P5.
There were also quotations, which implied the importance of evidence-based care like “there are new methods of care and treatments like monitoring the cuff pressure or closed suction. I am a senior expert and because of that I study articles and I have become familiar with these. But others cannot make use of research evidence” P9.
4.2. Artistic Needs
The head nurses’ experiences showed that to get managerial competence, they need some artistic competencies which include communication, creativity, critical thinking, controlling tension, fury and opposition, creating motivation in the staff, negotiation techniques and eventually body language and public effect.
In relation to communication, participant number 3 stated, “the ICU is a stressful unit. But if the head nurse can behave properly, she/he can prevent at least 70 percent of the tensions” P3.
The participants stated that there are many occasions in the unit, which is unique and needs creative decision-making. “I have placed all the basic required devices by each patient so that the nurses hardly leave the patients alone to get these devices” P1.
The participants stated that they should not obey the orders blindly. “There are some things that we remind the doctors of and we find faults with them. We should not blindly accept whatever they say” P10.
“For the patient who had a good blood pressure at the beginning and now suffers from hypotension, our duty is not just checking the blood pressure, but we must have a diagnosis and detect its probable cause” P9.
The above quotations express some of the aspects of the skills for critical thinking. All participants thought of the intensive care unit as a unit with potential for much tension. Therefore, they believed that they must be able to overcome the tensions and oppositions while controlling their anger.
“At this moment, I might treat them harshly, but the next day I behave in a way as if nothing has happened, i.e. I try to forget yesterday and not continue my yesterday’s behavior” P7.
“Once there was a fight between Ms A and Dr. C. I talked to Dr. C and asked him/her to revise his/her behavior. Of course, I talked to the doctor in a way that she/he does not get upset and she/he only finds out her/his mistake.” P3.
All participants emphasized on the significance and necessity of motivation for work at the intensive care unit. In this regard, participant number 1 cited the role of the head nurse in increasing the motivation of the staff at the intensive care unit; “the staff at the ICU must have motivation. If I assist them to the most possible extent or provide some facilities for them, they will certainly work better” P1.
The participants stated that for satisfying the unit requirements and managing the staff, they should negotiate with the authorities and sometimes even implore them. “I present evidence and convince the authorities that this workforce is not qualified for this unit”. They believed that the head nurse of ICU must have the the ability to impact upon others. “The authorities do not listen to my words … Dr. A (the head) applies most of my suggestions and words” P5.
4.3. Technical Requirements
The technical needs actually include those with the most psychomotor dimension. This theme consists of classes of technology application, working and keeping equipments, the skill of intensive clinical care, controlling infection, and work safety. The participants thought of the need for being trained to work with computers as one of their major technical requirements. They believed that they must be able to work with computers, whether for recording and following the works or for internet communication, and also for satisfying the need for scientific resources.
“Now that all the nursing works and services must be recorded on the system, certainly we cannot work without familiarity and skills for computers” P3.
The participants counted the presence of many devices and equipments as one of the features of special units. For example, one of them stated, “now we have about 60 - 70 devices in the ICU; we must be assured that the personnel can work with them and also can keep them, and I should also be sure about its proper use” P2.
The participants stated that attention to and awareness of what improves the staff’s work safety and what results in safety in patient care has great importance in the special unit. “Safe and helpful care, for both the patient and the nurse, brings about less hurt to the patient” P4.
4.4. Organizational Needs
The four categories, which created the theme of organizational need, were the requirements created as a result of attendance in the nursing class or the changes and priorities of the organization. These categories include ethics, professional rules, financial-official rules, clinical authority and validation.
All the participants accepted their knowledge shortage in ethics and professional rules and they stated that they had not received any training in this relation during their higher education and if they had had any, it had been too poor.
“I used to associate ethics to mood and these sorts of things until last week when I took the occupational ethics class. Thereafter, I found that I had mistaken. That is because we have not read anything in this relation before” P9.
The subjects of this study knew the need for awareness of financial and official issues was important because of three aspects; firstly for following their own rational and logical requests, secondly to defend their subordinate staff, and thirdly for significant and efficient presence in the meetings.
“When you take part in a meeting or when you have an official or financial request, they will easily get rid of you if you do not know their rules. Or optimistically speaking, when you know the financial-official rules you can have both rational requests and make use of the opportunities for improve things” P1.
The participants thought of the role of head nurses in the intensive care unit to be important in the implementation and monitoring, validation process and clinical authority; hence they believed in the necessity of awareness about its implementation process. For example, one participant stated, “we are very involved in validation. Some things in this relation like logging, controlling infection and audit, are very good and they contribute to improving things. I should know them” P2.