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1 Chapter I BACKGROUND 1.1 Brief introduction Head nurses are the ones in charge of managing human resources, medical equipment, financial resources and information to ensure the provision of quality health care services in hospitals They also connect hospital’s orientation, goals and tasks with staff who provide daily care for patients The managerial competence of a head nurse is assessed through the competencies in terms of expertise, human resources management, thinking, leadership and finance management Head nurses’ managerial competence has an impact on patient care outcomes at hospitals This study describes the managerial competencies of head nurses at central hospitals in Hanoi and proposes measures to improve their managerial competencies to enhance the quality of patient care 1.2 Reasons choose research topic Improving quality of health service delivery is urgently needed to attract and create trust for patients In which, developing human resources is obviously a decisive factor Recognizing this, hospitals have paid attention to improve managerial competence of head nurses However, when implemented in hospitals, managerial competence of head nurses is still limited, especially in resolving interdisciplinary relationships, strategic planning, personnel management, resources and financial management Therefore, in order to capture the overall picture of managerial competencies of head nurses at central hospitals in Hanoi and propose measures to improve their managerial competencies to enhance the quality of patient care, the author conducts a research thesis with the title “Managerial competencies of head nurses at central hospitals in Hanoi” 1.3 Study aim and research questions 1.4 Object and scope of research Research object was managerial competencies of head nurses at central hospitals in Hanoi through the survey conducted on hospital chiefs and vice chiefs of nursing, head nurses and staff nurses Research place and time: The study was conducted at central hospitals in Hanoi: Viet Duc University Hospital, National Pediatric Hospital, National Psychiatric Hospital, Vietnam National Cancer Hospital (also known as Hospital K), E Hospital, Hanoi Medical University Hospital, Huu Nghi Hospital from 2017-2018 Data collected includes both primary and secondary data The study focuses on researching and evaluating managerial competencies of head nurses at central hospitals in Hanoi according to 05 main categories: technical skills, human resource management skills, conceptual skills, leadership and financial management skills 1.5 Research process Research theoretical basis and overview Identify research gaps develop models and research hypotheses collect and analyze data present discussions and propose recommendations 1.6 New contribution of the thesis New academic and theory contributions The thesis systematizes general theoretical issues about the managerial competencies of head nurses, factors affecting their managerial competencies The results of the study will make certain contributions to finalizing the theoretical framework for the assessment of managerial competencies of head nurses in Vietnam The study used a scale which is the set of criteria to evaluate managerial competencies of head nurses which was applied in Vietnam for the first time The aim of this study is to describe the managerial competencies of head nurses at central hospitals in Hanoi and propose measures to improve their competencies The following questions were addressed in this study: Therefore, the study is the basis for further studies to continue finalizing the set of Firstly, what were included in the head nurses' managerial competencies measurement framework? Secondly, how is the managerial competencies of head nurses and patient care results related? patient care was developed and tested in this study Therefore, the research results reflect the Third, what factors of head nurses' managerial competencies should be improved most? Fourth, what factors affect the managerial competencies of head nurses? Practical contributions The study applied several methods and multi-dimensional views to synthesize, evaluation criteria close to the health system in Vietnam in the near future A research model between head nurses’ managerial competencies and results of reliability; supplement and develop methodology in evaluating the managerial competencies of head nurses; and proposing feasible solutions analyze and evaluate the head nurses’ competencies Each method and viewpoint was applied appropriately according to each research question This thesis can be used a reference for other researchers who are interested in evaluating the managerial competencies of head nurses in particular and assessing managerial competencies in general The study results are also the basis for managers to develop appropriate policies for head nurses and nursing system in Vietnam 1.7 Structure of the thesis The thesis includes introduction, conclusion, tables, figures, charts, list of references and chapters: Chapter 1: Background Chapter 2: Rationale for managerial competencies of head nurses Chapter 3: Research Methodology Chapter 4: Assessment of managerial competencies of head nurses at central hospitals in Hanoi Chapter 5: Solutions to improve managerial competencies of head nurses by 2025 CHAPTER 2: RATIONALE AND OVERVIEW 2.1 Hospital nurses and head nurses 2.1.1 Hospital nurses Nurses are technical and professional officials in healthcare, who directly give care or assist in caring for patients at medical facilities Nurses have specific tasks such as performing or supporting in patient care, assist the implementation of patient care techniques, monitoring vital signs, helping the doctor, giving first aid, implementing Good Storage Practices of medicine and assets, participating in health education, practicing medical ethics, complying with medical professional regulations and law The main professional duties of nursing: Health counseling and education; helping patients with personal hygiene, mental care, nutrition care; rehabilitation care; care giving for patients with indications for surgery or procedures; medicines for patients; end - of - life care delivery for patients in the dying stage and death patients; implementing nursing techniques; monitoring and evaluating patients; ensure safety and prevent medical errors; writing medical records 2.1.2 Hospital head nurses Head nurse is the nurse in charge of staff nurses in a department who is responsible for the performance of nursing in their department The head nurse is also an intermediate nurse, who is responsible for directing the implementation of strategy planned designated by the hospital director of nurse Responsibilities of head nurses Patient care management: Head nurse is the person in charge of organizing nursing care of patient in each department To effectively manage patient care, the head nurse needs to focus on directing and managing patient care delivery, including: Understand the disease and psychological status of each patient in their unit; Organize care to meet the needs of patients; ensure follow doctor's indications effectively; Ensure that nursing techniques are followed by all staff nurses; ensure full compliance with regulatory and professional standards Staff management: Educate and build an ethical and professional working environment for each staff nurse; Assign work in accordance with the ability of each individual; Train and create favor conditions for personnel to continue their professional development of qualifications and skills; Evaluate task accomplishment and job performance of personnel This is one of the most important tasks of a head nurse; Protect each individual in the unit from others, even before themselves; limit words that hurt employees' honor, protect individuals in the unit from outside communication, professionalism, knowledge, business skills, all intersecting with criticism Unit - hospital management: Professional management: Ensure that the rules, policies, professional processes are followed by everyone Minimize differences in the implementation of professional technical processes; Human resource management: Ensure that resources are used effectively and for the right purposes; Management of infrastructure, equipment, consumables: Ensure that resources are used for the right purposes and effectively; Management of working environment: Ensure the leadership competencies In studies around the world, this approach is often applied to research of senior nursing managers such as nursing directors and hospital chief of nursing In ANA's approach, the capacity of a head nurse consists of two groups of factors: Competency in management practice and the required practice of nursing and management expertise Following this approach described above, ANA follows the nursing manager's decision-making and implementation process in accordance with department and wards are always clean and tidy; ensure safety for patients and health workers; Management of ethics and service culture: Create caring and ethical care environment, patient-center care in nursing and staffs help each other to ensure the the head nurses’ managerial competence This is an approach that separates activities according to the nursing process, although it also makes the assessment more specific to nursing, but in the context, the nursing process is understood differently in different best care service following patient rehabilitation 2.1.3 Quality of patient care and indicators reflecting patient care outcome at hospitals Criteria to assess head nurses in hospitals include criteria attached with the results countries, which is not yet commonly applied in Vietnam This set of standards should only be applied when studying on a group of nurses with a high level of homogeneity, such as at one hospital or hospitals of the same specialty, with the same characteristics Chase 1994's approach, which was used by Ten Haaf in measuring head of treatment and care of the hospitals These are the rate of patient’s falling, patient’s satisfaction towards nursing care, length of inpatient treatment, rate of pressure ulcers, average cost of caring per patient, rate of complications due to caring, hospital infection rate; cross-infection rates due to caring, rate of medication administration errors nurses’ competencies in 2007 and was reported by Chase himself in his doctoral dissertation in 2010 This is an approach that fully presents the features of the head nurses’ managerial competencies, and is also challenging when conducted on different specialized nursing groups, therefore, the author will apply this approach in this study 2.2 Managerial competencies of head nurses at hospital 2.2.1 Competency The definition of competency used by the author in this thesis “is the abilities 2.3 Factors affecting the managerial competencies of head nurses 2.3.1 Internal factors of head nurses Qualities and talents are very important factors for managers Qualities and of an individual, expressed in knowledge, skills and attitudes that contribute to the outcome of his or her work to achieve get the goals of the organization” talents are genetic or congenital factors The economic capacity of the head nurse himself also largely determines the managerial competence, which includes the family economy, their ability to business Business-minded people are often good managers Age and gender also significantly affect the managerial competence of head 2.2.2 Managerial competency Managerial competency is assessed based on the ability to apply knowledge and skills on management including knowledge of management skills and content Proficient implementation of management processes and working attitude based on a sense of responsibility, solidarity, self-discipline and for common sake 2.2.3 Brief summary of the assessment of managerial competencies of head nurses Katz has provided a legacy conceptual framework with threeskill approach includes technical skill, human skill and conceptual skill This is a general competence review for all managers, and does not reflect the characteristics of nursing and nursing management AONE has provided a conceptual framework of competency-based theory for nurse manager leadership This model captures competencies in the areas of nurses Older managers are often more experienced than young people, while young people are more active than older people 2.3.2 Hospital’s factors Elements of human resource management: Quality and planning of head nurses; Recruitment: enlist good nurses who graduated from well-known training facilities; assign head nurses in the right position, right forte; Remuneration also significantly affects the managerial competence of head nurses Offering head nurses good incentives will stimulate them to promote their capacity and potentials, show their inquiring mind, passion for work and career aspirations; Factors from senior leaders of head nurses, doctors and staff: Attention of leaders and the board of directors, heads of department; the dependence on doctors’ CHAPTER indications and medical intructions; staff Cultural and organizational factors of hospitals and patients: Hospital policies and mechanisms; hospital culture; patient overload 2.3.3 Factors outside hospital Government mechanisms and policies, nation's culture, cooperation between hospitals; coordination of nursing training between hospital and training facilities; international cooperation; patients’ cooperation are also the factors that affect the RESEARCH METHODOLOGY 3.1 Design and selection of research framework managerial competencies of head nurses Figure 3.1: The conceptual framework used in this study 3.2 Sample size and method 3.2.1 Sampling method Hospitals deliberately selected include general hospitals, specialized hospitals, large hospitals and small hospitals t at central level that located in Hanoi Convenience sampling of hospital chiefs and vice chiefs of nursing, head nurses and staff nurses was conducted to find those who are willing to share information In each hospital, the research was carried out on hospital chiefs and vice chiefs of nursing, head nurses and staff nurses in each unit under convenience sampling method 3.2.2 Sample size The author included 14 hospital chiefs and vice chiefs of nursing, 60 head nurses and 538 staff nurses in this study 3.3 Data collection 3.3.1 Secondary data collection Secondary data was collected from management agencies including Administration of Medical Service - Ministry of Health, Department of General Administration at hospitals The researcher reached out to collect data, collate and compare data, and review data to ensure the data was consistent and reliable 10 Next, logistic regression analysis will evaluate the effects of the above 3.3.2 Primary data collection The researcher interviewed the research subjects with questionnaires designed for head nurses and staff nurses (see appendix for the survey questionnaire and questionnaire design) and then entered and cleaned the data 3.4 Data management and analysis 3.4.1 Research process The research process of the thesis is implemented through the main stages: (1) classified components on variables that reflects the quality of nursing activities The results of logistic regression analysis will clarify the relationship of each factor, compare the relationship between the factors, and orient the improvement of executive quality of head nurses Finally, although all staff nurses access the same questionnaire, there is still a possibility that differences exist in the evaluation between groups by age, gender, experience, etc Preliminary research, (2) In-depth quantitative research In particular: Preliminary research: The research focuses on developing research indicators, identifying variables used in the research, making questionnaires and preliminary analysis 3.4.3 Methods to identify strengths and weaknesses of managerial competencies - The distance between the expected competencies and the current competencies of the head nurses as assessed by staff nurses was calculated by the of questionnaires by qualitative methods In-depth quantitative research - Piloting on 100 subjects and assess the uniformity of the scale, adjust the scale to eliminate questions that completely reduce the quality of the scales difference between the average of expected score (the requirements for head nurses by 2025 set out by chief and vice chief of nursing) and the average score of the current managerial competencies of the head nurses as evaluated by staff nurses - The distance between the expected competencies and the current - Conducting the surveys on research subjects (14 chiefs and vice chiefs of nursing, 60 head nurses and 538 staff nurses in 60 departments of 07 central hospitals in Hanoi), describing characteristics of study population, carrying out basic statistical analysis competencies of the head nurses as assessed by themselves was calculated by the difference between the average of expected score (the requirements for head nurses by 2025 set out by chief and vice chief of nursing) and averages score of the current managerial competencies of the head nurses as evaluated by themselves 3.4.2 Data cleaning and analysis Quantitative analysis: mainly to test the uniformity of the scale, principal component analysis and logistic regression analysis - Each distance was divided into high and low group The high group included criteria with higher average score than the median, the low group included criteria with lower average score than the median Testing the uniformity of the scale is a technical method to check variables in each target group to see if there are similarities in measurement or not This test will help reshape the structure of these factors more clearly and logically through the identification and elimination of interference factors and increase the reliability of - Strengths were determined as the criteria had both of these above distance at low group - Weaknesses were determined as the criteria had both of these above distance at high group and the average of Importance lied above the median Weaknesses was input data Principal component analysis (PCA) is the second quantitative analysis tool to help organize survey variables from the questionnaire into groups of indicators an important basis for recommending solutions to improve managerial competencies of head nurses in hospitals Each group of indicators will represent a factor of competence of head nurses PCA helps determine significant factors and reshape the structure of head nurses’ competencies into main criteria These criteria will be used to evaluate the importance of each competency indicator and to assess the quality of nursing activities In addition, component analysis helps to synthesize survey variables into main components and will be the input for the regression analysis to assess the impact on the quality of patient care 11 CHAPTER ASSESSMENT OF MANAGERIAL COMPETENCIES OF HEAD NURSES AT CENTRAL HOSPITALS IN HANOI 4.1 Head nurses at central hospitals The youngest studied head nurse was 34 years old and the oldest was 60 years old, 49% of them were over 40 years old In terms of education level, the majority of head nurses (75%) hold a university or higher degree, this confirms the role as well as the importance of technical training for each head nurse to meet 52 out of 60 head nurses took short-term training on management, yet there were two of them who had not been trained for management 4.2 The current status of managerial competencies of the (studied) head nurses at central hospitals in Hanoi 4.2.1 Job performance of head nurses 66.7% of departments had less than 30 staff nurses; meanwhile there were only departments (6.7%) that had many staff nurses (over 50 nurses) The head nurses who took part in the questionnaire survey said that they spend a little time on planning, most of them spend less than 15% of their time planning Whereas the time spent on organizing operation activities and leadership was relatively appropriate, most head nurses responded that they spent between 16-30% of the time on this activity The majority of head nurses focused on controlling nursing activities Head nurses encountered difficulty most in planning, of them (accounted for 11.7%) admitted that planning faced many obstacles However, in general, it can be seen that currently head nurses have been facilitated to practice nursing management fairly well; over 70% of the head nurses said that their management activities were carried out in favourable or very favourable conditions 4.2.2 Research results on the requirements and importance for managerial competencies of head nurses The technical skills of head nurses were determined based on 11 criteria These criteria with the highest requirements included evidence-based practice; and comprehensive understanding of patient classification system Meanwhile, the criteria with the lowest requirements were knowing and good practice of medical records, understanding of nursing care regulations The most important criteria included understanding of nursing practice standards, nursing care planning, and understanding of nursing care regulations The least important criteria included practice clinical skills in 12 nursing, comprehensive understanding of patient classification system, good infection control practice, and evidence-based practice Human resource management skills of head nurses were determined based on 12 criteria The most demanding criteria included effective communication and effective discipline Meanwhile, the criteria with the lowest requirements were good sense of humor and optimistic The most important criteria were constructive performance evaluation and staff development strategies The least important criteria included having appropriate retention strategies, good recruitment strategies, good clinical examination, good sense of humor The head nurses’ conceptual skills were determined based on criteria The most demanding criteria were mastering nursing theories and good knowledge of ethical standards and principles The criteria with the lowest requirements were having strong political stance and having strategic planning/ goal development The most important criteria included mastering nursing theories, having knowledge about legal issues related to nursing care The least important criteria were having good administrative/organizational theories, having knowledge on the overview of quality management process Leadership skills of head nurses were determined based on 14 criteria The most demanding criteria were being able to manage time well and knowing how to assign work properly Criteria with the lowest requirements included subtle and effective in expressing power and empowerment appropriately; research and proposal of process The most important criteria were having ability to train employees, having good time management, interdisciplinary care coordination Meanwhile, the least important criteria included having good knowledge of policies and procedures, and ability to make decisions Financial management skills of head nurses were determined based on 07 criteria The most demanding criteria were having appropriate measures to increase productivity, having appropriate measures for cost containment and cost avoidance practices Criteria with the lowest requirements included having ability to develop/find financial resources and having good unit budget control measures The most important criteria were having appropriate measures for cost containment and cost avoidance practices, having appropriate measures to increase productivity Meanwhile, the least important criteria included having good unit budget control measures and having ability to develop/find financial resources 4.2.3 Research results of current managerial competencies of head nurses Technical skills: As seen by staff nurses, head nurses had performed well the 13 14 evidence-based practice and fluent use of information technology and computers financial management competence However, understanding of nursing practice skills and understanding of nursing care regulations of head nurse were rated as less competent The studied head nurses evaluated themselves to be the most competent at understanding of nursing care regulations and understanding of patient classification system Meanwhile, fluent use of information technology and computers and nursing care planning were rated as less competent Human resource management skills: Staff nurses evaluated that head nurses were humorous, optimistic and had reasonable retention strategies, on the other hand they rated Length of service was inversely correlated with technical skills (beta = - 0.338, p = 0.019); educational level was positively correlated with personnel management skills (beta = 0.031, p = 0.031) and positively correlated with conceptual skills (beta = 0.094, p = 0.028); length of service had a positive correlation with personnel management skills (beta = 0.222, p = 0.043); managerial qualification was positively correlated with conceptual skills (beta = 0.134, p = 0.031) in the managerial competencies of the head nurses head nurses as poorly competent at being able to communicate effectively, and not having good clinical examination Head nurses perceived their communication skill and group process to be most effective Meanwhile good sense of humor and team building 4.4 Relationship between managerial competencies of head nurse and patient care outcomes Technical skills had negative correlation with the rate of patients falling (beta = - strategies were assessed to be their worst competence by themselves Conceptual skills: Staff nurses assessed head nurses’ competence to be best at having strong political stance and mastering nursing knowledge, worst at strategy planning and goals development, teaching/learning theories Whilst head nurses perceived 0.267, p = 0.012), and was inversely correlated with the rate of pressure ulcers (beta = 0,216, p = 0.001), There was a negative correlation between technical skills with the rate of medication administration errors (beta = -0,153, p = 0.021) Human resource management skills were inversely correlated with the rate of pressure ulcers (beta = - themselves as good at mastering nursing theories, understanding ethical standards and principles, in contrast they rated themselves poorly competent at strategy planning and goals development having an overview of quality management process Leadership skills: Staff nurses evaluated that head nurses had the best competence 0.182, p = 0.035) Leadership skills had a negative correlation with the rate of medication administration errors (beta = -0.94, p = 0.029) Conceptual skills and financial management skills were not correlated with patient care outcomes 4.5 General assessment of managerial competencies of (studied) head nurses at in interdisciplinary care coordination, knowledge of policies and procedures, and worst in problem- solving and organization of unit work The studied head nurses evaluated themselves to be the most competent at organization of unit work and workflow process central hospitals in Hanoi 4.5.1 Strengths in managerial competencies of head nurses Strengths in technical skills of head nurses: The skills that head nurses performed and being able to solve problems appropriately and thoroughly They saw themselves weak at creating sophisticated and effective motivational strategies and demonstrating power and empowerment appropriately Financial management skills: As seen by staff nurses, head nurses had performed well (strong points) were those of which the two distance were short when compared with the expected competencies Strengths in nursing technical skills included understanding of nursing care regulations; having knowledge of and good practice records management; understanding nursing practice skills; good practice of nursing well cost-benefit analysis and capital budget forecasting However, cost containment and cost avoidance practices, and unit budget control measures of head nurses were rated as less competent The studied head nurses evaluated themselves to be the most competent at clinical skills Strengths in human resource management skills: Strengths in personnel management skills of head nurses included good clinical examination competence; being unit budget control measures, cost containment and cost avoidance practices, and worst at having appropriate measures to increase productivity, capital budget forecasting 4.3 Factors related managerial competencies of head nurses Individual demographics factors such as age, management experience, length of optimistic; ability to implement group process; having staff development strategies; having appropriate retention strategies Strengths in conceptual skills of head nurses: Strengths in head nurses’ conceptual skills included having strong political stance; knowledge of legal issues related to nursing service, educational level, managerial qualification explained 39.1% change of technical competence, 56% change of personnel management competence, 52% of change in conceptual competence, 33% change in leadership competence and 34% change in care Strengths in leadership skills of head nurses: Strengths in leadership skills of head nurse included being able to solve problems appropriately and thoroughly; ability of 15 16 training staff; understanding policies and procedures; having good stress management solving, time management, organization of work of unit and workflow process, and skills; research and propose processes Strengths of financial management skills of head nurses: Strengths in financial management skills of head nurses included ability to develop/find financial resource; ability to implement unit budget control measures; ability to analyse cost- benefit 4.5.2 Limitations and causes in managerial competencies of head nurses Limitations and causes in technical skills of head nurses: Criteria for technical skills of head nurses were considered weak when there was a interdisciplinary care coordination Causes: Firstly, nursing work was very hard and full of pressure from work processes, patients and patients’ family members These pressures created conflicts frequently Head nurses faces difficulties and were even impossible to resolve all these conflicts Secondly, the above weaknesses were common and required a long time for the head nurses to undergo, learn from experience and overcome Thirdly, the fact that job description for each position had not been completed lead to the overlapping, difference between the expected and the actual competencies assessed both by staff nurses and themselves plus the score for the importance was high Weaknesses included nursing care planning, evidence-based practice, and good application and use of new technology unmanageable, not fully assigned coordination of common workloads of their unit Limitations and causes in financial management skills of head nurses: These weaknesses included the ability to control unit budget and take appropriate Causes: Head nurses had not been trained in planning nor updated with knowledge about evidence-based practices and new technologies, or maybe they were subjective, got used to following their past experiences, habit and feeling leading to missing out of required steps In addition, since hospitals had no requirements or regulations on measures to increase productivity The causes for these weaknesses were mainly due to the starting point of head nurses They were the ones who switched from practicing as an RN in the beginning, and they had not been trained on financial management Only at hospital had department of mandatory implementation of the above contents, the implementation was not consistent Limitations and causes in nursing skills human resource management skills: Weaknesses in human resource management skills of head nurses included the ability of effective communication and effective staffing strategy finance, there was no team specialized in financing at department level In addition, little had head nurses been trained on financial management as enterprise managers had Furthermore, nursing activities were mainly performed following processes At the time of the study, head nurses paid more attention to safety and proper implementation of Causes: Head nurses had not been trained or well trained on communication skills They often conducted communication when they felt it necessary or upon requests, they had not had long-term communication strategies The development of staffing strategies procedures than to productivity measurements This is one of the weaknesses that needs to be improved, especially in public hospital of head nurses was limited due to the specific nature of healthcare service that had divided nurses into specialties and departments This division had previously been interpreted by default as the possibility of chief or vice chief of nursing or the hospital board of directors Therefore, head nurses were still passive to carry out this skill Limitations and causes in head nurses' conceptual skills: Weaknesses in head nurses’ conceptual skills included being able to teach and study well; having strategy planning and goal development Causes: Head nurses had not been trained in pedagogy The teaching/coaching process was mainly practical with hands-on instructions, without any long-term and wellplanned training strategies Well planning also needs to improve because they had not yet paid enough attention to it, plans developed was mainly developed similar to the plans of previous years Limitations and causes in head nurses’ leadership: Weaknesses in leadership skills of head nurses included the ability of problem- 17 CHAPTER SOLUTIONS TO IMPROVE MANAGERIAL COMPETENCIES OF HEAD NURSES BY 2025 5.1 Orientation to improve managerial competencies of head nurses 5.1.1 The need for improving managerial competencies of head nurses In order to improve the quality of care, ensure safety for patients and enhance performance of head nurses, in the coming years, the Health sector needs to pay attention 18 - Adopt appropriate policies to support and encourage skillful staff and acknowledge the contributions of head nurses Receive high consensus of head nurses in self-planning, looking for opportunities to improve their own skills 5.2 Recommendations to head nurses 5.2.1 Recommendations for improving technical skills in managerial competencies of head nurses The relationship between length of service and technical skills is statistically to following issues: 1- Transforming nursing policy, nursing management system 2- Increasing both in quantity and quality of human resources for nursing and significant and negatively correlated (beta = -0.338, p = 0.019) Therefore, in addition to improving managerial competencies, head nurses still need to update and practice nursing skills regularly so they can participate in the development of technical midwifery 3- Transforming service attitude and style and improving quality of care towards patients’ satisfaction 4- Issuing nursing care process and implementation guidelines processes and supportive work for management Recommendations to management units: It is necessary to supplement the regulations and compulsory requirements for head nurses on updating, supplementing and improving technical skills annually 5.1.2 The goals of improving managerial competencies of head nurses from now on to 2025 By 2025, Vietnam needs to achieve the following goals: 1- Enhancing the completion of legal provisions related to the role, position, functions, obligations and responsibilities of head nurses 2- Developing and standardizing skill sets for head nurses; as a basis for staff nurses to strive for, and a basis for recruiting head nurses with good education level and management qualifications as well 3- Consolidating training curriculum, syllabus, teaching facilities and standard teaching staff toward practical and effective teaching/coaching about resource management – administration 4- Enhancing the effectiveness and efficiency of nursing management of the current head nurses 5.1.3 Viewpoint on improving the competencies of head nurses by 2025 Improving the competencies of head nurses in particular and nurses in general should: Be implemented scientifically, persistently and aggressively Be fully allocated resources on policies, personel, facilities and conditions for - practicing theories obtained Be supplemented with “work management tools” to ensure feasibility and effectiveness Criteria that need to be focused on improving include nursing care planning, evidence-based practice, good application and use of new technology Head nurses need to complete the planning in steps as follows: (1) Assessment; (2) Nursing diagnosis; (3) Care planning; (4) Implementation; (5) Evaluation (Kozier, B 2004) Evidence-based practices need to be based on four key aspects: (1) summarizing evidence from quantitative research; (2) clinical and technical evidence; (3) patients’ preferences and actions; (4) clinical state and circumstances: care environment, beneficial factors, harmful factors, etc In order to implement well the criteria of good use of information technology, a part from regularly attending training courses and updating knowledge, head nurses must proactively study and practice newly techniques and technologies, so that they can keep up with the development of nursing in Vietnam in the period 2020-2025 5.2.2 Recommendations for improving human resource management skills in managerial competencies of head nurses There was a correlation between education level (beta = 0.031, p = 0.031), length of service (beta = 0.222, p = 0.043) and human resource management skills, this was positively correlated Therefore, when planning and appointing, compulsory requirements and priorities for those who meet these criteria Criteria that need to be focused to improve include: Being able to evaluate staff 19 20 performance, being able to communicate effectively, having good recruitment strategy, prevent and control potential risks They also need to review and supervise regularly and being able to obey effective discipline, and have staffing strategy Therefore, head of nurses need to coordinate to develop a set of criteria for evaluating staff nurses’ performance, and detailed job descriptions for each position In addition, head nurses also need to perform well the organization of work of unit, create solidarity, and act as bridge for staff nurses to coordinate well to improve work efficiency, thereby creating the stature of the unit and building trust for patients 5.2.3 Recommendations for improving conceptual skills in managerial the implementation to gain experience and increase performance efficiency 5.3 Recommendations for hospitals to improve head nurses’ competencies Strengthen training and improve training quality: Attention should be paid to innovation of method of evaluating training effectiveness: standards-based assessment; pre-assessment; post-assessment, and re assessment after a certain time Use competency framework for head nurses competencies of head nurses There was a correlation between education level (beta = 0.094, p = 0.028), management qualifications (beta = 0.134, p = 0.031) and conceptual skills and that With the competency framework, Department of Personnel and Organization will design a questionnaire to evaluate each specific skill of head nurses using 360degree evaluation method Strengths and limitations of head nurses’ working skills can was positively correlated Therefore, education level and management qualifications should be set as standards when planning and appointing head nurses Head nurses need to focus on improving following criteria of conceptual skills: ability to teach well and study well, strategy planning and goals development In be pointed easily out after the evaluation Based on the evaluation results, senior manager can arrange and assign head nurse to suitable work positions to maximize their strengths while overcoming the remaining weaknesses Regularly assess head nurses using competency framework addition to being fully trained and possessing management qualifications, head of nurses need to obtain a certificate in pedagogy in clinical teaching and at the same time attend continuing medical education training courses at least 48 lessons in consecutive years or long-term courses like nursing specialist level 1, level 2; doctoral program in nursing, It is required to renew the assessment in order to improve managerial competencies effectively The most specific assessment tool is the management competency framework for head nurses, which provides specific and detailed criteria to evaluate the performance of head nurses Moreover, the assessment must apply the etc 5.2.4 Recommendations for improving leadership in managerial competencies of head nurses 360-degree evaluation method for true and fair view to determine qualified candidates to take up the position of head nurse Create work motivation for head nurses Head of nurses were less competent in time management, change process control, organization of unit work and workflow process, interdisciplinary care coordination These skills require head of nurses to have fundamental training in management skills as well as practical management experience for a long time + Monetary incentives and rewards: Promptly commend head nurses who gain achievements Head nurses who have outstanding achievements in their work should be rewarded in accordance with the law on emulation and commendation, get a raise ahead of time, be prioritized when being considered for higher positions Hospital leaders and chief of nursing need to have a strategy to train and improve managerial competencies for head nurses, regularly review and supervise so that timely changes are carry out to minimize errors + Spiritual incentives: There are various forms to honor and reward head nurses who are dedicated to take care of patients wholeheartedly, those who have made great and long-term contributions, for instance: emulation Fighter at grassroots level or 5.2.5 Recommendations for improving financial management skills in managerial competencies of head nurses Head of nurses were less competent in having appropriate measures for cost containment and cost avoidance practices, unit budget control, productivity increase ministerial level, medal “For People's Health, certificates of merit awarded by the director and by hospital, etc Build hospital’s culture based on the competency framework Hospital’s culture is created as a basis for forming working attitudes and In order to minimize the above shortcomings, head nurses need to develop detailed budget plan that covers every step of the implementation process, with measures to behaviors for staff in general and head nurses in particular Behavior and attitude are extremely important skills that are components of managerial competencies head nurses 21 22 5.4 Recommendations for state management agencies Ministry of Health leaders need to be aware of the significance, role and importance of managerial competencies of hospital head nurses in general to enhance the image and stature of head nurses and encourage them to promote their managerial competencies Renovating and perfecting policies, standards for the practice of head nurses’ managerial competencies will create a favorable legal corridor for the development of nursing system in Vietnam The Ministry of Health needs to develop and promulgate a framework for managerial competencies of head nurses Policies should be developed and favorable conditions for training centers to train skills and in-depth knowledge of management for hospital head nurses to CONCLUSION The study was conducted with the participation of 14 chiefs and vice chiefs of nursing, 60 head nurses and 538 staff nurses at central hospitals in Hanoi Some outstanding research results as follows: - Demographic information: Most of the studies head nurses were female (81.9%), the youngest was 34 years old and the oldest was 60 years old, 49% of them were over 40 years old In terms of education level, the majority of head nurses (75%) hold a university or higher degree, 87% head nurses took short-term training on management - improve their skills should be created In addition, activities to improve nursing skills should be integrated with the implementation of other plans Performance results of head nurse: The head nurses spent less than 15% of their time planning, 16-30% of the time on organizing operation activities and leadership The majority of head nurses focused on controlling nursing activities Length of service was inversely correlated with technical skills (beta = - 0.338, p = 0.019); educational level was positively correlated with personnel management skills (beta = 0.031, p = 0.031) and positively correlated with conceptual skills (beta = 0.094, p = 0.028); length of service had a positive correlation with personnel management skills (beta = 0.222, p = 0.043); managerial qualification was positively correlated with conceptual skills (beta = 0.134, p = 0.031) in the managerial competencies of the head nurses - Relationship between managerial competencies of head nurse and patient care outcomes: Technical skills had negative correlation with the rate of patients falling (beta = - 0.267, p = 0.012), and was inversely correlated with the rate of pressure ulcers (beta = -0,216, p = 0.001); there was a negative correlation between technical skills with the rate of medication administration errors (beta = -0,153, p = 0.021) Human resource management skills were inversely correlated with the rate of pressure ulcers (beta = - 0.182, p = 0.035) Leadership skills had a negative correlation with the rate of medication administration errors (beta = 0.94, p = 0.029) Conceptual skills and financial management skills were not correlated with patient care outcomes - Strengths in managerial competencies of head nurses: + Strengths in technical skills of head nurses included understanding of nursing care regulations; having knowledge of and good practice records management; understanding nursing practice skills; good practice of nursing clinical skills + Strengths in human resource management skills of head nurses included good 23 LIST OF RELATED MANUSCRIPTS clinical examination competence; being optimistic; ability to implement group process; having staff development strategies; having appropriate retention strategies + Strengths in head nurses’ conceptual skills included having strong political stance and knowledge of legal issues related to nursing care + Strengths in leadership skills of head nurse included being able to solve problems appropriately and thoroughly; ability of training staff; understanding policies and procedures; having good stress management skills; research and propose processes - Weaknesses in managerial competencies of head nurses: + Weaknesses in technical skills of head nurses included nursing care planning, evidence-based practice, and good application and use of new technology + Weaknesses in human resource management skills of head nurses included the ability of effective communication and effective staffing strategy + Weaknesses in head nurses’ conceptual skills included being able to teach and study well; having strategy planning and goal development + Weaknesses in leadership skills of head nurses included the ability of problemsolving, time management, organization of work of unit and workflow process, and interdisciplinary care coordination + Weaknesses in financial management skills of head nurses included the ability to control unit budget and take appropriate measures to increase productivity * Study limitations and orientation for further studies - The study sampling method was convenience sampling; therefore, the representativeness of the sample was not as superior as that of random sampling - As the survey was based on cross - sectional study, the research results only assessed managerial competencies at the timing of the snapshot It could not be as superior as case–referent study (case-control study) or study following groups of individuals over time (cohort study) - Quantitative research method could not understand deeply about the causes, strengths and weaknesses in the managerial competencies of head nurses Further studies may add qualitative research to have a deeper look into this issue - The framework has been applied effectively overseas, however, when applied in Vietnam some criteria need to be revised accordingly The framework offers scales that was applied only to the nursing system, evaluation from doctors on the managerial competencies of head nurses should be supplemented to the study Nguyễn Văn Uy, Nguyễn Thị Ngọc Huyền, Nguyễn Thị Lệ Thúy (2018), “Improving managerial competencies of head nurses at SIMACAI District Hospital - Lao Cai province”, Yearbook of the National scientific conference on the assessment of vocational training policies, job creation and ensuring basic social services for ethnic minority people from Doi Moi Reform to present, Labour and Social Publisher Company Limited, 2018, 66-83, Hanoi Nguyễn Văn Uy, Nguyễn Thị Ngọc Huyền (2018), “Nursing and results of patient care in Hanoi city: current situation and recommendations”, Journal of Economics and Development, Vol 252 (II), June 2018, 86-94 Nguyễn Văn Uy (2018), “Current situation of managerial competencies of head nurses at Simacai General Hospital - Lao Cai province”, Journal of Economics and Forecasting, Vol 33, November 2018, 57-60 - Nguyễn Văn Uy, Nguyễn Thị Ngọc Huyền (2019),” Improving managerial competencies of head nurses at central hospitals in Hanoi, Journal of Economics and Development, Vol 263, May 2019, 74-84  ... patient care outcome at hospitals Criteria to assess head nurses in hospitals include criteria attached with the results countries, which is not yet commonly applied in Vietnam This set of standards... important factors for managers Qualities and of an individual, expressed in knowledge, skills and attitudes that contribute to the outcome of his or her work to achieve get the goals of the organization”... of management skills and content Proficient implementation of management processes and working attitude based on a sense of responsibility, solidarity, self-discipline and for common sake 2.2.3