A Phenomenology of Communication and Nadia J Malabi MAN …€¦ · considering the complexitiesof clinical environment; a complex and cognitivecourse that is definedas choosing a

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Health Science Journal ISSN 1791-809X

2015Vol. 9 No. 6:12

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Research Article

Nadia J Malabi MAN RN1,2

1 StaffNurse,WomenandChildCareUnit,AsianHospitalandMedicalCenter,Muntinlupa,Philippines

2 GraduateStudent,PhDinNursing,UniversityofthePhilippines–NationalGraduateOfficeforHealthSciences,Manila,Philippines

Correspondence: Nadia J Malabi

[email protected] [email protected]

Staff Nurse, Women and Child Care Unit, Asian Hospital and Medical Center, Muntinlupa, Philippines

Tel: 632-906-279-7405

A Phenomenology of Communication and Decision-Making among Head Nurses and

Staff Nurses in a Managerial Job-Sharing Unit

AbstractBackground: Job-sharing isoneofthemost intriguing innovations inthenursingmanagementandadministration.Thisstrategyhasbeenintroducedto nursing since the late 1970s primarily to empower and retain staffnurses. Job-sharing is a flexibleworking arrangementwhich assigns twoormoreemployees(atanylevels)sharingthesametasks,responsibilities,and accountabilities, thereby dividing the amount of workload, helpingeach other, and learning from each other. In the Philippines, especiallyinnursing, job-sharing isnotwidelyexercisedduetosomereasonssuchas organizational structure, costs, and human resource managementissues.Since there isonlya fewnumberofhospitalswhichemploys thesaidworkingarrangement,aneedforunderstandingandknowledgeisofimportance.Theaimofthestudyistodescribetheexperiencesoftheheadnursesandstaffnursesinthedecision-makingandcommunicationaspectswhenjob-sharingatthemanageriallevelisemployed.

Method and material:Atotalof12nurses(n=4headnursesandn=8staffnurses) participated in this phenomenological inquiry. Semi-structuredinterview and protocol writing were utilized as tools to gather data.Descriptionsofexperiencesamongparticipantswereexplicatedfollowingthe Colaizzi’s mode of analysis and themes were presented in a tablethroughtheprocessofthematicanalysis.

Results and conclusion:Theconcept ‘need’was themain themeof thisstudy. There are six needs that occur from the approachof job-sharing.These needs were sorted from two areas of inquiry – decision-makingand communication. The needs in communication include ‘the need foridentification,’‘theneedforcompatibility,’and‘theneedforbelongingness.’On the one hand, the needs for decision-making include ‘the need fornegotiation,’ ‘the need for collaboration,’ and ‘the need for integration.’Furtherresearchisnecessarytostudyhowtheseneedsexistandsustainjob-sharinginnursing.

Keywords: Job-sharing; Decision-making; Communication; Head nurses;Staffnurses;Communication–decision-makingmatrixofjob-sharing

IntroductionJob-sharing in nursing has been identified as a useful strategyto retain and empower employees [1], to improve their job

satisfactionandphysicalhealthstatus[2],andtoimprovework-life balance [3]. Numerous professions have embraced thepractice of job-sharingmaking it popular among teachers andeducators[4,5],pharmacists[6],andentrepreneurs[7].

Received: May06,2015, Accepted: Oct07,2015,Published: Oct30,2015

2 This article is available in: www.hsj.gr/archive

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Job-sharing, as a type of flexible working arrangement, hasgained attention once again in research due to issues in thenursingprofessionsuchasnurseretention,nurseshortage,andjobsatisfaction[8].Arisingfromtheneeds,issues,anddemandsof the nursing profession are the nurse manager shortage[1,9], recruitmentand retentionofnursemanagers [10],nurseturnover[2],andagingnursingworkforce[11,12],which,yieldedto numerous innovations. One among the list of considerablechanges is the working arrangements, especially in theindustrialized countries. These suggested greater variation andflexibilityinhow,when,andwherepeoplework[3].Interestingly,several advantages of job-sharing have been cited amongliteratures.Itprimarilyallowsmoreflexibility[6],employeework-lifebalance[3], improvedfamily life[13],andpursuitofhighereducation[5,6,14,15],averredthatreducedstresslevelsamongkeyleadersmakessharedleadershipattractivesinceitdoesnotburdenanysingleleader.

Although literatures suggest that job-sharing has advantagesand benefits in nursing [16], there are some that have arguedotherwise.Job-sharing,likeotherstrategiesinmanagement,hasalsoitscomplexitiesandchallenges.ItwasdemonstratedinthestudyofCathmoir,Mullooly,Brewer&Millerthatworksituationslikejob-sharinghasapotentialforroleconflicts,possessiveness,andmisunderstandingofroleboundaries[17].Resistancetojob-sharingmakestheimplementationachallengingstep[5].

Further, studies increasingly suggest that in any profession orindustry,nosinglepersoncanbeperfectandrightall thetimeto manage an organization, thus the draw for job-sharing.KocolowskicitedO’Toole,Galbraith,andLawlerthatitisbecominga challenge fora single individual topossess skills andabilitiesrequired to competently lead an institution [5]. In addition, ithasbeenhighlyrecommendedthatthepersonalitiesofthejob-sharersmustbecompatible[4,18,19].

Duetotheadvantagesitofferstodifferentprofessions,nursinghasstartedtoadaptthisset-upparticularlyatthemanageriallevel.Knowntobeachallenginganddifficultrole,job-sharingaidsthemanagers toperformtheir tasksand responsibilitiesefficiently,increasingvisibilityandcoverageintheunit,andintegratingworkand life. However, there is a dearth of literature on the nursemanagers’ownexperiencesofpartnerleadership[20].Conceptssuch as decision-making, communication, accountabilities, roleboundaries, and competition are just few of the aspects thatarenotquiteunderstoodacross literatureswhen job-sharing isemployedatthemanageriallevel[15,19].

Decision-making is considered one of the most importantprocessesinmanagement;andselectingthetypeandmethodofdecision-makingisconsideredtobeoneofthemost importantskills of a manager [21,22]. It is a multi-factorial processconsideringthecomplexitiesofclinicalenvironment;acomplexand cognitive course that is defined as choosing a particularcourseofaction [22].However, theprocessofdecision-makingisnotquiteunderstoodespeciallyinthecontextofnursing[23].Headnursesandstaffnursesareexpectedtosharedecisionsastheyworktogetherintheunit.Thedynamicsandtheprocessaremuchunclearwhen job-sharing is employedat themanageriallevel. Hoffman, Aitken, and Duffield argued that there are

conflictsinthefindingsonthedecision-makingprocessesamongnursesfromdifferentcompetencylevels(i.e.noviceandexperts)[23].

Further, staff nurses are not exempted in playing a role indecision-making; they are stimulatedor encouraged to engageintheprocess[24]andmajorityofdecision-making ismadebythestaffnurses[25].Theseargumentsposeanotherissueinthedecision-making especially in the context of job-sharing. Thisisbecausetherearetwoormoreheadnursesthatstaffnursessharethedecisionswithratherthanthetraditionaloneofhavingsingleheadnurseinaunit.

Inaddition,decision-makingisbecomingatransactionalprocessnotonlybetweenaheadnurseandstaffnursesbutalsobetweentwoheadnurses.Similarly, leadershipskillsoftheheadnurses,inonewayoranother,mayimpactthedecision-makingprocessof the employees involved. In the study of Gunnarsson andStomberg,theresultshighlightedthecomplexitiesofleadershiprequiredindecision-making[26].

Despitearichheritageofrationalapproachestounderstandingdecision-makinginthenursingliterature[27]Thompson,Aitken,Doran, and Dowding argued that there are still key empiricaland theoreticalquestions that remainunanswered indecision-making [28]. Thus, it is clearer thatmanagement strategies orleadershipskillsinfluencethedecision-makingprocess.However,little is known about decision-making aspects when the job isbeing sharedby twoormoremanagers. In a studybyHardingandSque,theyarguedthatthereisnoresearchthatexplorestherelationshipandwhetherornotleadershipimpactsthedecisionsmade by nurses in senior clinical positions, specifically, wardmanagers [29]. Further, only the positive effects and benefitsofnurses’ involvementindecision-makingweregivenattention[30]. Concomitantly, employees have the impression that theycan actively shape the decisions in their organization [31].Since scenariosmay be completely different when job-sharingis employed at the managerial level, this present study seeksto describe the phenomenon of decision-making. A qualitativeapproachwas utilized in this study since evidence of decision-makingisobservableonlyinactionsperformedbythedecision-maker,makingitdifficulttomeasurewithquantitativemethods[27].

Apart fromdecision-making,communicationplaysakeyrole inanyorganizational levelsoranygivenworkplace.Creedleetal.arguedthatcommunicationisoneofthemostvitalcomponentstocreatesuccessinajob-sharingventure[32].Communicationinajob-sharingenvironmentmaybeanissuesinceitcandrawsplits[33]inarelationshipbetweentwopartnermanagersandamongstaffnurses.InthestudyofCreedleetal.,findingsrevealedthatregardless of the overall satisfactionof the staff tomanagerialjob-sharing,theyfeltthattheydidnotlikehavingtocommunicateissues perceived as sensitive to both of themanagers, if theirprimaryrelationshipistoonlyoneofthemanagers[32].

It is unclear how communication takes place most especiallywhenissuesarehighlysensitiveandwhenoneisuncomfortabledealingwithbothmanagers.Incontrast,inaquantitativestudybyAcorn,Williams,Dempster,Provost,andMcEwan,staffnurses

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were satisfied if they feel the open flow of communicationbetweentwomanagers[34].Thesefindingsdrawablindspotontheaspectsofcommunicationwhenjob-sharingisemployedatthemanageriallevel.

MethodologyPhenomenological designThisstudy isanchoredbyphenomenologicaldesign,qualitativeapproach. Phenomenology describes the meaning for severalindividualsoftheirlivedexperiencesoraphenomenon.Thelivedexperienceitself,asdescribedbyparticipants,isusedtoprovideuniversal description of the phenomenon [19]. The design ofthisstudyis laiduponthedescriptiveperspective,settingasidequestionsofanyrelationshipofthephenomenontotheuniverse.

Thisstudyacknowledgedthatthereisagapinunderstandingofdecision-makingandcommunicationaspectsat themanagerialset-upamongnurses;andthatdescriptionofexperiencesofthenurseswillbenefitthenursingmanagementandpractice.

Setting and participantsThe locus of the study was a 200-bed capacity, tertiary,governmenthospitalinMetroManilacateringtonon-contagious/non-communicable diseases (http://www.jrmmc.gov.ph). Itservesasatraininghospitalforstudentsandprofessionalsfromvarioushealthandsciencefieldscomingfromdifferentcitiesandprovinces of the Philippines. Specifically, the study took placein two, separate medical-surgical units where job-sharing ispracticedbytheheadnurses.Thepositionstillremainedasfull-timewhereineachheadnurseworkedfull8-hourshiftandsharedoverallresponsibilitiesandaccountabilitiesasapair.Thehospitalemploys thiswork arrangement primarily in departmentswithhighercensusofpatientsandhighernumberofnursingandnon-nursingpersonnel.

The study involved two participant cohorts – head nurses andstaffnurses(Table 1).Eachcohorthasauniquesetofinclusionandexclusioncriteria.Headnurseswhoparticipatedinthestudywerethosewho(a)engagedinajob-sharingrolewiththesamepartner head nurse for at least six months, (b) have had job-sharingexperienceatthemanageriallevelforatleastayear,(c)havehadmanagerial experience for at leastfiveyears, (d) age30-60yearsold,and(e)eithermaleorfemale.Staffnurseswhotookpartinthestudywerethosewhowere(a)workingataunitwhereinjob-sharingsetupisemployed,(b)workingforatleastsixmonthsinaunitwhereeligibleheadnurseswereassigned(c)workingasastaffnurseforatleastoneyear,and(d)20-50yearsold,and(e)eithermaleorfemale.

Atotaloftwelveparticipants(headnursen=4,staffnursen=8)from two different units were recruited as participants in thestudy. Selection of participants followed a purposive samplingwhereintheresearcherselectedtheindividualsforstudybasedontheknowledgeofaphenomenonforthepurposeofsharingtheexperience.

Instrumentation

This study utilized semi-structured interview withsupplementationofprotocolwriting.Semi-structured interviewencouragestheparticipantstosharetheirthoughts,experiences,andfeelingswhichtheresearcheranalyzesandinterprets.

Data gatheringUpon signing of informed consent, participants were askedto answer a sheet (devised for each cohort) inquiring for theirdemographicinformation.Thestudyutilizedatwo-partapproachof data collection – protocol writing and semi-structuredinterview.Throughprotocolwriting,theparticipantswereaskedtoanswersituationalquestionsrelatedtotheirdecision-makingandcommunicationexperiences.Participantsweregivenampletimetoanswerthequestionsandwereprovidedwithspacesonthequestionnaireforwriting.

Subsequently,aconversational-style,semi-structuredinterviews(30 – 60 min) commenced. The interview was guided by thefivedescriptivequestionswhichwereconcernedwithdecision-makingandcommunicationaspectsallowingtheparticipantstofreelyexpresstheirexperienceswiththeresearcher.

Ethical considerationsInformedconsentwasobtainedfromtheparticipantsbyexplainingfirst theaimof thestudyandthedetailsof theirparticipation.Each participantwas given a copy of signed informed consentform.Permissiontoaudio-recordtheinterviewwassoughtafterensuringconfidentiality.Emphasisonthevoluntaryparticipationandtherighttowithdrawatanytimeonthecourseofthestudywas upheld prior to data collection. Participantswere assuredthat their identitywouldbekept inprivate through theuseofalpha-numericcodesandpassword-protectedmedia.Permit toconduct the study and ethical approvalwere sought since thestudyinvolvedhumaninteraction.

Mode of analysisAnchored by the descriptive phenomenological design,descriptionsofdecision-makingandcommunicationexperiencesamong staff nurses and head nurseswere explicated followingtheColaizzi’smodeofanalysis(Table 2).

The responses from protocol writing were merged with thesemi-structuredinterviewstranscriptions.Thethematicanalysis(Table 3) included thefindingof significant andmanifest ideaswithinthetranscriptsandgroupingthemintocategoriesbeforereducingthetextsintosmallercodedunits[35,36].Thisprocessrepeatedmanytimeswhichledtowardsfurtherabstractionandresultedinsixmajorthemesasrepresentedbyamatrix(Table 4).TranslationoftheresponsesandverbatiminEnglishlanguagewascarriedoutbyanEnglish languageexpertsidebysidewiththeformulationofthemes.Thisfacilitatedthetexturaldescriptionsoftheexperiencesinthestudy.Thetranslationswerethenencodedopposite theoriginal texts to observe for congruencywith thedescriptive texts. Dendrogramming was used to organize themeaningunitsintocategories,clustersofthemes,andthemes.

Validation of correspondence was finally conducted after thethematization of data and formulation of the researchmodel.Thiswasachievedbygoingback to theparticipantspresenting



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their respective interview transcripts and explaining theresearchmodel.Majorityoftheparticipantsexpressedthatthefindingsofthestudywerecongruentwiththeirdescriptionandinterpretation.Toensurecredibility,memberchecking[37]wasconductedfollowingthestepsonTable 5.

ResultsThis qualitative inquiry covers two aspects of job-sharing:communication and decision-making. Anchored by the fivegeneral questions and vignettes, participants’ responseswere grouped according to each aspect. The six themes wereclusteredinrelationtothecommunicationanddecision-makingexperiences.

Interestingly, the themes emergedwere collectively termed as‘needs.’ Since theaimof the studywas to investigateonwhattheparticipantsdoandwhattranspiresduringtheprocess,theauthor eidetically described and captured the phenomenonthroughneedsasessentialtotheheadnursesandstaffnurses.Theneedisdefinedassomethingwhichisnecessaryandarousesan action to take place. This gives purpose and drives certainbehavior in the job-sharing unit. The actual experience of theparticipantscreatesandsatisfiestheneedsallatthesametime,ratherthanrequiringtheneeds(asaprerequisite)tobepresenttoexperience

Whatisactuallyexperienced.Inotherwords,participantsalreadyhavetheexperiencesinajob-sharingunit,determinedtheinnatetransactions(communicationanddecision-making)present,andrecognizedtheneedsaslivedandaspartofthephenomenon.

Theneedsofcommunicationinclude‘theneedforidentification,’‘theneedforcompatibility,’and‘theneedforbelongingness.’Ontheonehand,theneedsfordecision-making include‘theneedfornegotiation,’ ‘theneed for collaboration,’and ‘theneed forintegration.’

The needs in communication1. The need for identification: Who am I talking to?Themainquestion‘whoamItalkingto?’capturedoneofthemostintriguing questions of peopleworking in a job-sharing set-up.Sincejob-sharingrequirestwoormorejob-sharingindividuals,itisimportanttounderstandtowhompeoplearecommunicatingwith.Participantswereabletorelatetheirexperiencesduringthecommunicationprocessandwereabletoexpresstheiranswersbydescribing thedifferentaspectsof identitiesofheadnurseswho shared equal roles and responsibilities. Collectively, theseaspectswereconveyedas‘thetriadofidentities.’Threeaspectswere identified as the bases for identification – experience,expertise,andpersonality.Theseguided theparticipants (headnurses and staff nurses alike) in communication as they worktogether.Theywereabletodeterminewhatfactorsmightaffectthe communication styles and what anchored their reactionswhilecommunicatingwithtwodifferentheadnurses.

Identity in this context refers to the qualities of a head nursewhichmakesheruniquefromherpartnerheadnurse;thismayalsodictatethecommunicationstylesofeachparticipantwithaparticularheadnurse.

Expertise, or forte, refers to the specialized knowledge orskillsof theheadnurse ina specificarea (i.e.medical-surgical,intensivecare).Participantsknewtowhomtheymayconsultorclarifymatters as they render various patient careprocedures.Becomingfamiliarwiththeexpertiseoftheirheadnurseshelpedthemtoaskthe‘right’questions,tofacilitatesatisfyinganswers,

Participant Age in years Gender Civil status

Highest educational attainment

Position No of years in current position

No of years in job-sharing set-up Area assigned

01-AAL <30 Female Single BSNursing Staffnurse 1-2+ 1-2+ PayWard202-JEE <30 Female Single BSNursing Staffnurse 3-4+ 3-4+ PayWard103-CFC 30-45 Female Married BSNursing Headnurse 5-9+ 5-9+ PayWard104-GTL <30 Male Single BSNursing Staffnurse 3-4+ 1-2+ PayWard205-JTV 30-45 Female Married BSNursing Headnurse 5-9+ 5-9+ PayWard26-Apr <30 Female Single BSNursing Staffnurse 3-4+ 3-4+ PayWard207-AMI 30-45 Female Married BSNursing Headnurse 5-9+ 3-4+ PayWard108-CDP <30 Female Single BSNursing Staffnurse 3-4+ 3-4+ PayWard109-RTG <30 Male Single BSNursing Staffnurse 1-2+ 1-2+ PayWard110-JTD <30 Female Single BSNursing Staffnurse 5-9+ 1-2+ PayWard111-FDR 30-45 Female Married BSNursing Headnurse 5-9+ 1-2+ PayWard212-GBC <30 Female Single BSNursing Staffnurse 3-4+ 3-4+ PayWard2

Table 1Participants’DemographicProfile.

Steps Procedures

First Readingandre-readingeachtranscriptuntilobtainingthegeneralsense

Second ExtractingsignificantstatementsfromeachtranscriptThird Formulatingmeaningsfromthesignificantstatements

Fourth Sortingthemeaningsintocategories,clustersofthemes,andthemes;

Fifth Integratingthefindingsintoanexhaustivedescriptionofthephenomenon

Sixth Describingthefundamentalstructureofthephenomenon(researchsimulacrum)

SeventhValidatingthefindingsfromtheresearchparticipantstocomparetheresearcher'sdescriptiveresultswiththeir

experiences.

Table 2Colaizzi’smodeofanalysis.



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Theme Sub-themes Descriptions

1.Needforidentification

Triadofidentities:Expertise,experience,andpersonality

Strictversuslax;defenderandthenot

Head nurses have three aspects to relate their identities to –expertise,experience,andpersonality

Expertiseorforte,maybeattributedtospecializedknowledgeorskillsinaspecificarea(i.e.medical-surgical,intensivecare)

Experiencesaretheknowledgeandskillsgainedfromexposureindifferenteventsorscenarioswhichmaybeappliedinthefuture

Personalitiesarethecollectionofemotionsandattitudereflectedby theheadnurses’actionsasperceivedbyco-headnurseandstaffnurses

Headnursesarebeing referred tobeing strictor lax. Strictnessmeansactingincloseconformityorsetofprinciples,whilelaxnessisnotbeingstrictenough,tense,orrigid

Identificationistheactoffindingwhoiswho;ortheassumptionofwhoapersonis

2.Needforcompatibility

Adjustingtodifferences(i.e.personalities)

Blending with (dealing through informalconversations)

Compatibility (achieved through adjustmentandblending)

Knowingthattherearedifferences,oneshouldbeabletoadjust,aspartofworkingrelationship

Staffnursesandheadnurseslearnhowtoadjust

with the differences as they work together; both parties havetheopportunitytoworkwitheachother;theycheckfortherighttimingwhen toopen certain concern; test thewatersbybeingsensitivetocuesormood

Staffnursesmakeefforttoblendinbyinformalconversationandinjectinghumor

Compatibility is a valuableproductof adjustment andblendingwhichcreatesstrongerbondbetweenjob-sharers.Itappreciatesthecomplementaryshadesoftwodifferentheadnurses,ratherthanhighlightingcontrastofidentities

Itmeansbeingabletoexistandperformtogetherwithouthavingtochange

3.Needforbelongingness Togethernessandrelatedness

Togetherness is a state of being close to another head nurse,creatingharmony,strengtheningpartnership.

Relatednessreferstobeingconnectedorfindingcommonground.Head nurses share similarities such as being both females,belongingtosamegenerationgroup,tenureintheorganization,withinthesamerangeoflengthofexperienceasheadnurses.

Belongingness is the feeling of becoming a part of a group orteam;itisempoweredbytogethernessandrelatedness

4.Needfornegotiation

Consultingwithsupervisorortoinstitutionalpolicies

Consensus

Challenges;conflictandconfusion

Consultingwith supervisorwhen issues are notmanageable intheheadnurses’ level;beyondthecontrolorscopeofthefirst-levelmanagers;differencesindecisionsofheadnurses

Staffnursesmayhavedifferentbeliefs, views, ideaswhichmaychallenge the decision-making process; personal concernsmayalso a factor, thus reaching majority decision or consensus isessentialinmakingdecisions

Conflictandconfusionarisesonsituationswhenthereweretwoormoreoptions;to choosewhichisbetterorrightthingtodo(i.e.charting,documentation,medication);checkinginstitutionalpolicieswhenuncertainwhichpracticetofollow

Negotiationenablesboth

sidestofindanewunderstandingandawayforward;decision-makinginapprovalofbothparties

Table 3ResultsofThematicAnalysis.



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5.Needforcollaboration Teamworkandsupport

Teamwork isbeingabletoworktogether inpursuitofcommoninterest rather than his or her own; it is essential especiallyworkinginanenvironmentcomposedofdifferentpeople

Supportreferstoassistancereceivedfromcolleagues,especiallyheadnurses,itdriveshead

nursesandstaffnursestoworktogetherandachievesuccess

Collaborationistheactofworkingtogethertoachievecommongoal. This is evident by the teamwork among members andsupportforeachother.

6.Needforintegration InvolvementandInterdependence

Involvement refers to engagement or participation in grouptransactions.

Interdependencemeansperformingtasksinmutualdependence.

Theneed for identification refers to theneed to fuseormergeone’sknowledge,skills,abilitiestocontributeinachievingcommongoal throughwhich can be displayed through involvement andinterdependence.

Patientcare isaround-the-clockactivity,therefore,theneedtointegrateone’sselfindiscussionsanddecision-makingtoachievesafeandqualitycare.

Layers of experience Questions asked Responses Resulting states Thematic description

Communication

WhoamItalkingto?

TriadofIdentities:Expertise,experience,andpersonality

Theneedforidentification

Theneedforidentificationmeansknowingandrecognizingtheaspectsofheadnurses’reflectionofidentity.Inthiscontext,participantsexpressedexpertise,experience,andpersonalityasdeterminantsofidentity.Thetwotypesof

personalities

Whatunifiesheadnurses’differences?

Adjustment Theneedforcompatibility

Theneedforcompatibilitymeansbeingabletoexistandperformtogetherdespiteofthedifferencesandownidentitieswithouthavingtochange.Blending

Inwhatstatedoesauthenticcommunicationtakeplace?

TogethernessTheneedforbelong-ingness

Theneedforbelongingnessreferstotheneedoffeelingapartoftheteam,broughtaboutbyworkingtogetherandsharingcommonground;astrongfeelingofconnectionRelatedness

Decision-making

Whatshouldbedoneintimesofdecisionconflicts?

Consultation Theneedfornegotiation

Theneedfornegotiationistheneedthatenablesbothsidestofindanewunderstandingandawayforward;decision-makinginapprovalofbothpartiesConsensus

Whatstrengthensourdecisions?

Teamwork Theneedforcollaboration

Theneedforcollaborationentailstheneedtoactofworkingtogethertoachievecommongoal.Thisisevidentbytheteamworkamongmembersandsupportforeachother.Support

Whoaretheactorsinthedecision-making?

InterdependenceTheneedforintegration

Theneedforintegrationreferstotheneedtofuseormergeone’sknowledge,skills,abilitiestocontributeinachievingcommongoalthroughwhichcanbedisplayedthroughinvolvementandinterdependence.

Involvement

Table 4TheCommunication-Decision-makingMatrixofJob-sharing.

Steps Procedures1 Interviewerdiscussedinterviewquestionswithparticipantsattheendofeachinterview;2 Interviewerreturnedideasbacktoparticipantstorefine,rephrase,andinterpret;3 Eachparticipantwasgiventhechancetodiscussthefindingsininformalpost-interviewsession

4 Participantswhowerewillingtoprovidefeedbackonthetranscriptsoftheirowninterviewaswellasevaluatetheresearchfindings.Asessionwithasampleoffiveparticipantsmaybedone.

Table 5MemberChecking.



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to relatepatientcasesduringconversation,and to seekadvicewhenperformingpatientcare.

Similar to expertise, experiences also became a basis forcommunication. Experiences refer to the knowledge and skillsgained from exposure in different events or scenarios whichmaybeappliedinthefuture.Headnurseswereguidedbytheirexperiencewhentheyaskquestionsfromtheirstaffnursesaboutpatient cases. They believed that they becomemore effectiveadvisors and trainers as theyprovidetips to their staffnurses.Theyfeltmoreconfidentingivingsuchadviceiftheywereabletoexperienceitinthepast.Thiswasexpressedbytheheadnurses,astheyfeltateasewhentheirpartnerheadnursetookoverthethingswhichtheyknewtheyencounteredbefore.

Arguably, the most controversial determinant of identitydescribedbytheparticipantswasthepersonality.Personalityinthiscontext isthecollectionofemotionsandattitudereflectedbytheheadnurses’actionsasperceivedbyco-headnurseandstaffnurses.Theyhaveidentifiedtwoextremeswheretheirheadnursescouldbedescribed–thestrictandthelax.Aparticipantexpressedthisinthefollowingstatement:

“Thetwoofthemhavedifferentpersonalities…Imeannotreallytheirattitudebutthepersonality…oneislaxwhiletheotheroneisstrict.”(R2)

Interestingly, strictness and laxnesswere associatedwith theircommunicationexperiences.Staffnursesinparticularknewthatastrictheadnurseemphasizedcloseconformitytopoliciesasshegivesadvice,callstheirattention,orreprimandsthem.Ontheonehand,a laxheadnursefocusesonestablishinga less-pressuredenvironment, creating a more comfortable interaction. In linewiththis,participantsdeterminedotherextremesofpersonality–thesearethedefenderversusthenotdefender(opponentorothersimilartermwasnotusedasitdenotesnegationorrivalry;

participants emphasized only the potential of head nurses todefend them or not, rather than opposing them). This wasspecifically observed during nurse-doctor issues. Participantsexpressedtheseinthefollowingstatements:

“There’salso[a]timewhenforexamplethisheadnurseIknowwillcatchyouifthereisaproblem.Butifthisheadnurseworkswith you, she’ll really point a finger at you…there are reallydifferences,theonewhowilllayblameonyou‘that’syourfault’.Theotheronesinceyouworkwithherwillsupportyou.”(R1)

“Ifit’sAshewilldefendyou,ifit’sBit’suptoyou…you’reholdingyourlicense…(if)she’sworkingonthesamedutywithyoushewilldefendyou…butitdependsifwhatyoudidisreallygravethentheycandefendyou.”(R4)

Overall, participants have expressed that the need foridentificationwhilecommunicatingwithjob-sharingheadnurseswas crucial because it directed their behavior and reactionstoward their respectiveheadnurses.On theonehand, itdoesnot restrict their relationships as other participants also havetheir own set of personalities. This study did not intend todetermineeachparticipant’spersonalitiesandhowdiditaffectthe communication process, rather, it focused on the generaldescriptionofwhathappenedandwhatactionstookplaceduringtheirinteractionasapartofjob-sharing.

The need for compatibility: What unifies the differences?The question ‘what unifies the differences?’ directs to a newunderstanding of their communication experiences when job-sharing head nurses possessed differences in identities. Thisanchoring query generated responses to determine whathappened when participants encounter their respective headnurses.Majority of the participants expressed adjustment andblendingasmeanstofacilitatetheirinteraction.Thesemeasureshelped the unit to maintain harmonious relationships. Theyarticulated that compatibility was important to focus on thecomplementary shades of personalities rather than seeing thecontrast.Overall,thiscanbeexpressedinaformula:

a+b=c(adjustment+blending=compatibility)

Aheadnursestated:

“Sowehavetoadjusttothepersonality…onhowtodealwiththem.”(R7)

Adjustmentreferstotheactofmodification(approachorstyle)toachievecertainordesiredoutcome.Similartoanyrelationship,adjustment is one ingredient to appreciate the differences –whetherknowledgeorskillsbroughtbytheheadnurses intheunitwhileworkingtogether.Thiswasmostlyevidentwhenstaffnurses asked their head nurses of particularmatters regardingpatientcare.Astaffnurseexpressedthatshewouldcheckonherheadnurse’smoodfirstbeforeaskingheranything.Thisminimizeduncertaintytowardsaparticularheadnurse’sresponse.

Meanwhile, blending was described as another factor in theequation. Itreferstotheabilitytominglewithrespectiveheadnurses and co-staff nurses during conversations. Participantsarticulated that therewere threeways to start a conversationwithaparticularheadnurse.Theydescribedthemas‘testingthewaters,’ ‘moodchecking,’and‘righttiming.’Theseactionswereconveyedinthefollowingstatements:

“BecauseIknowheadnurseA’sattitude…it’slikeI’llstartit...bysharingstorieswithher…Iwillmatchwithhermood.”(R6)

“Ishare jokeswithbothofthem…theybothget it…theyarehappy,butifit’swork,it’swork…ifit’sjustjokingaround,it’sokwith(headnurse)B,that’swhenyousee(headnurse)B.”(R4)

When adjustment and blending were combined, compatibilitysetsin.Thisisbecausesuchbehaviorsilluminatedcomplementarypersonalities of the head nurses. Some participants expressedthatcommunicationstrategiesbecameautomaticasaresultoffamiliarizingone’sselfwiththeheadnurses’wayofinteracting.The need for compatibility refers to being able to exist andperform togetherdespite thedifferencesandunique identitieswithouthavingtochangeone’sidentity.

3. The need for belongingness: In what state does authentic communication take place?‘In what state does authentic communication take place?’inquireswhatcommunication,aspartofjob-sharingandnursingenvironment,bringstotheparticipantswhiletheyinteract.Theneedforbelongingnessreferstotheneedof feelingavaluable



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part of the team, as appreciated through working togetherand sharing commonground. This creates a strong connectionamongtheparticipants.Headnursesinparticularexpressedthatcommunication per se made job-sharing favorable because itstrengthenedthebondbetweenjob-sharersandmadethestaffnurses feel that there were two ‘mothers’ willing to listen tothem.Although head nurseswere on full-time, 8-hour shiftingbasiseach,theunitfeltthatheadnursecoveragefrommorningtoeveningmadeallthedifference.

‘Causeitisdifferent,itseemsMa’amthereisheart(inwhatyoudo),it’slike…youfeelthatwheneveryouleadthem,justlikeyoutoyourchildren.”(R7)

Relatedness, asa componentofbelongingness, isdescribedasthe state of sharing commonalities or similarities brought byexchanging of ideas and thoughts. Points of relatedness wereevidentwhen head nurses brought up conversation pertainingtotheir families,beingamothertotheirchildren,havingbeenin the institution for almost the same lengthof tenure, andofcourse,belongingtothesameagegroups.Aheadnurserelatedhersatisfactioninhavingapartnerheadnurse inthefollowingstatement:

“OfcourseMa’am,becauseifyouhaveacompanionthenthereissomeonewhomyoucanventyourfeelingstoo,right?”(R7)

Ontheonehand,anotherfactorintheneedforbelongingnesswas the feeling of being together. Togetherness is the state ofbeing close together which creates harmonious and strongrelationship.

Relatedness and togetherness were observed as participantsinteractwitheachother.Staffnursesontheothersideperceivedthat these components strengthened the partnership ratherthan drawing split communication between the head nurses.Collectively,thismadeeachmemberoftheunitfeelpartoftheunit,thustheneedforbelongingness.

The needs in decision-makingThe need for negotiation: What should be done in times of decision conflicts?Actions in thedecision-makingprocesswhileworking in a job-sharing permit the question ‘what should be done in times ofdecision conflict?’ Considering the variety of identities – fromheadnursetostaffnurselevelanddifferencesinopinion,ideas,and thoughts of the participants, challenges in the form ofconflictsandconfusionmightarose.Thus,thequestionofwhatshouldbedone intimesof such situationbroughtattention inthis study. The need for negotiation emerged as the result ofparticipants’ responses when inquired about decision-making.This is theneed thatenabledboth sides (headnurseand staffnurse) tofindanewunderstandingandaway forwardas theyshare the responsibilities of deciding together especially inpatientcare.

“Weopttochoosewhatwethinkisbetter,forthebettermentoftheward…Iwillbaseonwhatisgoodforthepatient…forme,Ichoosetheonethathasarationale.”(R2)

This need sought approval from both parties prior to makingdecisions. Since the study is anchored by a descriptivephenomenologicaldesign,determiningwhathappensduringthedecision-makingprocess,ratherthantheoutcome,wasthefocusoftheinterview.Thedatacollectionprocedurewassuccessfulingathering participants’ experiences ofwhat they did andwhattheythinkwhentalkingabouttheirdecision-making,ratherthanknowing how each member made steps in the process. Headnursesadmittedthattheyalsoengagethemselvesindiscussionpriortodecision-making.

“Ifshewillsuggestsomethingthatyouthinkisgood,youcangetit…”(R5)

“Wegathertheideathatwethinkwillhavegoodeffects.”(R7)

“MaybeifIknowthisisbetter,Iwilltellher.AndthenIwillciteexamplessoshewillbepersuaded,soIcanconvinceher.ButifIknowherdecisionismorereasonable,thenokay.”(R11)

Evident from the participants were two means to negotiate:conferring with the supervisor and consulting institutionalpolicies.Wheneverheadnurseshaddifferencesintheirdecisionsor implementing actions, staff nurses always sought first theinstitutional policy. This usually satisfies the questions arisingfrom the situations. Overall, these actions resolve challengesbroughtaboutbythedecision-makingintheunit.

“Youknowthisheadnursewantsthis,thentheotheronethat,soifit'slikethis,heorshewillendupfollowingthepolicyabidedbythenursingtrainingoffice...soitwillgobacktowhatthepolicyreallyis.”(R1)

“But in casewe are there,we talk it over because usuallywehavemonthlymeetings,sotogetherwithoursupervisor,weareabletotalkabouteverything...usuallyvotingamongus... 'whois in favor?' Like that, so if there aremajorities, then they arefollowed.”(R12)

The need for collaboration: What strengthens our decisions?Thepotentialoftheparticipantstoactonandforthedecisionsisreferredinthisstudyastheneedforcollaboration.Consequently,itanswersanotherdecision-makingquestion,‘whatstrengthensourdecisions?’Theneedforcollaborationentailstheneedtoactofworkingtogethertoachievecommongoalwhilemakingsafeandpatient-centereddecisions.Thisisevidentbytheteamworkamongmembersandsupportgivenforeachother.

Teamworkinthecontextofthestudyreferstounitingtheactionsof different individuals while putting common goals in higherprioritythanhisorherown.Support,ontheonehand,isequallythe assistance offered and received by eachmember as he orshewentthroughthedecision-makingandevenafterchoosingamongtheoptions.

“WithheadnurseA,youwillbepushedtodowhatisright,withhead nurse B is just okay, you won’t be afraid of your wrongdecisionbecausesheistheretosupport(you)”(R6)

Whenbothwerepaired, teamwork and supportwere likely tostrengthenthedecision-makingactivitiesofnurses.Interestingly,



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headnursesfeltthesameneedwithintheirlevelbecauserolesand responsibilities called for collaborative actions displayedthroughteamplayingandsupportingeachother.

The need for integration: Who are the actors in decision-making?Theneed for integrationcompletes the listofneedsdescribedin thedecision-makingand communicationof theparticipants.Thisreferstotheneedtofuseormergeone’sknowledge,skills,and abilities to contribute in achieving common goals. Thiscan be displayed through involvement and interdependence.Involvement and interdependence answer the question, ‘whoaretheactorsindecision-making?’Asdefined,involvementistheengagementorparticipationinthegrouptasks,inthiscontext,thedecision-making. This was complemented by interdependencewherein participants felt that therewas amutual dependencewhenmakingdecisions,especiallythecriticalones.Thisthemeexplainswhoparticipatesinthedecision-makingprocessoftheunit.

“Both of you are responsible for the unit … Both of you areaccountable…bothofyou,bothofyouareresponsible,so if indecision-making…Youhaveequalresponsibilitieswhenitcomestoyourpatients,everythingisonbothofyou.”(R1)

Importantly,headnursesexpressedthattheywerebothinvolvedand displayed interdependence when theymake decisions fortheunit.Decisionswereassociatedwithstaffnursedisciplinaryactions, staffingandscheduling,delegationof tasks,employingpair-up (buddy system) among the staff nurses, and othermanagerial concerns.All headnurses stated that theywereallhavethesameprivilegesofbeingheardandmakingthefinalsaywhentheydiscussimportantissuesintheunit.

Collectively, the foregoing themes are presented using adata display called matrix. A matrix is simply described as anintersectionofcolumnsandrows[38].Itisatypeofdatadisplay,differentfromanetwork,whichisutilizedmainlytosystematicallyarrangeandpresenttheresearchquestionsandanswersathand.Becauseitorganizesalltheinformationcoherentlyandconcisely,itfacilitatesthedrawingofconclusionsbymerelylookingatitorreadingthroughit.Inthecontextofthisstudy,thedatadisplayis called ‘The Communication-Decision-making Matrix of Job-sharing.’

DiscussionTheoverallresultsofthestudyformulatedthesixneedsofjob-sharingunitasillustratedbyamatrixcalledTheCommunication-Decision-makingMatrixofJob-sharing.Theneedinthecontextofthisstudyreferstosomethingwhichisnecessaryandarousesan action to take place. This gives purpose and drives certainbehavior in the job-sharing unit. It suggests that the needsidentifiedareall interrelatedand interdependent,however,donotnecessarilytranspireinsequence,noritdonotimplythatacertainneedmustbemetfirsttoachieveotherneeds.Majorityoftheparticipantsexpressedsatisfactiontowardstheset-upandpreferred thiswhenworking in big areas, such as thosewhichhavehighpatient census andhighnumberofhealth care staffemployed.Staffnursesalsoexpressedthattheylookforwardin

workingwithapartnerinthefutureiftheywouldbepromotedasaheadnurse.

Challengesanddemandsbroughtbythechangesinthenursingmanagement have motivated this qualitative inquiry. In adeveloping country like the Philippines, there is only a littleunderstanding on decision-making and communication amongnurses. Decision-making and communication experiences mayjustberecalledandcannotbeobservedinactual,hence,theuseof descriptive phenomenology design. Since job-sharing is notwidelyemployedinthecountryespeciallyinthehealthsector,itisnecessarytoconductinvestigationsuchasthis.Thefollowingentailsthediscussionofthethemesemergedinthisqualitativeinvestigation.

The needs in communicationJob-sharing entails higher frequency of communication sincethere are two head nurses involved in the process. The headnursesarebelievedtobepeoplehavingmoreexperiencesandpossessingexpertiseinthefieldresultingfromtheirtenureandexposureinthepractice.Dubourg,Ahmling,andBujasassertedthatnurseswhobecomeexperiencedandknowledgeablewithadvancedclinical,management,leadership,andhumanresourceskillsreachthepointintheircareerwheretheybecomesuitablecandidatesfornursemanagerroles[15].Theirdistinctexpertiseand experiences helped them become adaptive and quick inanalyzingthesituation.Benner,ascitedbyEdwardsarguedthatgrowthinnursingexpertiseischaracterizedbymovementfromrelianceonrulestotheuseofclinicalexperience[39].

Being an expert means being able to possess a specializedbodyofknowledge,havingextensiveexperienceinthatfieldofpractice,havinghighlydeveloped levelsofpattern recognition,andbeingacknowledgedbyothers [39,40].As theparticipantsworkedtogether,itwasclearthattheheadnurses’expertiseandexperiencesinfluencedhowtheycommunicatewitheachother.

Thedifferencesofheadnursesintheiridentitiesposedimpacttotheircommunicationexperiencessincetheymadevaluableinputandcontributiontotheknowledgeandskillsofthestaffnurses.Atthesametime,staffnurseswerefamiliarizingthemselveswitheachheadnurse’sidentities.

Throughcommunication,staffnurseswereable to identifyand‘label’ their head nurses in terms of their personalities. It is acommonplaceinajob-sharingset-upthatthejob-sharers'actionsreflecttheiridentities.Thestrongestdescriptionsemergedwereeither‘beingstrict’or‘beinglax.’Meanwhile,headnurseswerenot exempted from seeing each other’s differences. They feltthattheirpersonalitydistinguishedthemfromtheirpartnerheadnurse.

Participants expressed that comparison between head nurseswas inevitable. They recognized this because staff nurses andhead nurses get to work with each other in a shifting basis.Particularreasonforcomparisonwasstaffnursesfelt‘hesitationversuscomfort’whencommunicatingand‘pressureversusease’atmospherewhileworkingwithspecificheadnurses.Staffnursesinthistypeofset-upmightlookforsomethingofsignificanceorin favorwith themwhileworking. Dubourg et al. have argued



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that staffnurses valued the ‘empathic’ approachofoneof thejob-sharingmanagerswhencommunicating[15].

Theneed for identificationwas crucial to eachmemberof theunitbecause ithelped themestablish theworking relationshipandmadedealingwiththeheadnurses’differencesmucheasierandbearable.

The need for compatibility unifies the overall differences inidentities. This need arouses adjustment and blending to takein.This combinedactionmakeseveryparticipantworkactivelyon their communication strategies. Adjustment and blendingwerelearnedovertime,asaresultofinteractingwithrespectivehead nurses in a shifting basis. Participants expressed thatrather than focusingon thedifferences asdetrimental to theircommunication, they took this as an asset instead. It meansthattheyvaluethecombinationofpersonalitiesofheadnursesbecause they felt variety and well-roundedness. This pavedtheway to appreciating the complementary attributes insteadof comparing and contrasting. Further, when staff nurses andheadnurses learnedhowtoadjustandblendwitheachother,compatibility sets in.This resulted todiminishedoccurrenceofmisunderstandingsandcommunicationsplits.

In a study by Rogers and Finks, they found that when apartnership is consisted of two committed and compatibleemployees, who have unique individual strengths, benefitedtheemployer [6]. This is supportedby thepresent study sinceheadnursesexpressedthattheyfeltconfidenttoberotated indifferent wards and assigned challenging tasks because of theexperiencetheygainedfromjob-sharing.InseparatestudiesbyBranineandSpencer,ascitedbyWoodhouse,Finn,andJohnson-DeWit,theyassertedthatcompatibilitywasthekeystoneforthejob-sharersexperiencingthejob-sharing[33].Dubourgetal.ontheonehand, argued that a sharedposition canbe successfulwhenadministeredbytwoskilledmanagerswhobringdifferentpersonalities with different views and different ideas, creatingfresh,stimulatingsolutionsthatmayreachbeyondthepotentialofthesingleindividual[15].

Woodhouseetal.arguedthatsharingofarolemaynotalwaysbeeffective for situations thatpersonalitiesmaynot get alongandthatcompatibilityisachallenge[33].Itshouldbenotedthatwhentwopersonsoperatingwithintherolewerenotcompatibleordidnotmeethalfway,therewouldbeariskofcommunicationbreakdown.

Communicating with job sharers on a regular basis, resolvingconflict,andsettingcleargoalsandresponsibilitiesarenecessaryinthistypeofworkingarrangement[6].Moreover,thispresentstudy affirms the findings of Dubourg et al. wherein the job-sharingnursemanagersmustbeabletocomplementeachothertomaintain harmonious relationships among head nurses andstaffnurses[15].

Apart from the need for identification and compatibility,participants also sought the need for belongingness; the thirdneed arising from the communication experiences of theparticipants.Thisneedreferstothenecessityof feelingbelongastheyexchangefeelings, thoughts,and ideaswiththepersonthey talk to. Head nurses expressed that communication with

their partner head nursewas as important as interactingwiththeir staffnurses. This need for belongingness encouraged thestaffnursestofeelaspartofthefamily,ratherthanfeelingleftoutfromthepartnershipoftheirheadnurses.

Headnursesfromtwoseparateunitswereallfemales,married,and working mothers. These similarities established a senseof belongingness with their partner head nurses and at thesame time helped them to relate their feelings and emotions.It also strengthened theirworking relationship as they felt theconnectionbetweenthem.

Headnursesexpressedthatbeingawomanandamotherhelpedthemtodealwith their staffnurses,considering that theyalsohadtheirowndifferences.Itwasconveyedthattherewasmorepersonaltouch;enablingthemtotreattheirstaffnursesliketheirchildren. They also valued the skill for listening and providingfeedback. Itwasexpressed in the interviewsthat incorporatingmotherly behaviorwas a tool to establish trust between headnursesandstaffnurses.Sun,Lim,Jiang,Peng,andChencitedintheirstudythatfemaleshavefocusonintimacyandsolidarityinthe communication processwhich tends to strive for harmonyand rapport, and give positive evaluation to others’ opinion.Thisisverytruewiththeset-upoftheparticipants.Womenareknowntoberelationship-oriented[41,42].

The needs in decision-makingNo team can be exempted from challenges. Conflicts for theparticipantswere inevitabledue to theirdifferences inopinionandideasastheymakedecisions.Thisisusuallyevidentduringtheir involvement inpatient-careandpersonalconcerns. Itwasarguedthatmostorganizationsaresusceptibletoconflictandtheclinicalsettingisnoexception[43-45].Involvementoftwoheadnursesandthestaffnursesinanyorallaspectsoftheirworkingset-uphadapotentialformisunderstandingandconfusion.

The outcomes of conflict, especially in a role shared by twoemployees, affect the members as well as organizations, andmanagement of interpersonal conflict determineswhether theoutcomeswill be positive or negative [46-48]. Some source ofconflict arose from nurse-doctor relationship, which was notsubstantiated in this study. However, emphasis on the actionsmade for these conflicts was entertained. As highlighted inAllen’s work, potential areas of conflict were managed ornegotiated, predominantly by the nursing staff [49]. Hence, itwas necessary for the participants to dealwith the challengespromptly and effectively. Negotiating differences was the keysolutionforthesechallenges.Therewerethreeactionsthattheparticipantsdescribedastheynegotiatetheirdifferences.Thesewereconferringwiththeirsupervisor,consultingandconformingtotheinstitutionalpolicies,andreachingtheconsensus.

Theneedforcollaborationcapturesthegeneralanswerto‘whatstrengthens’ thedecision-makingprocess in a job-sharingunit.As explicated earlier in this study, decision-making is a multi-factorial process which may influence the outcome of patientcare.Similartojob-sharingset-up,theinputofeachheadnurseisequallyimportantforallstaffnursesbecausebothheadnursesholdthesameamountofaccountabilitiesandresponsibilities.



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Job-sharing accounts two individuals in the same level tocollaborateastheyweregiventheequalrolesandresponsibilities.Likewise,onthepartoftheheadnurses,theymadesurethatbothofthemhavetodemonstratesupportforeachother’sdecisions.An example of which is when they weremaking decisions fordisciplinary measures or giving considerations for staff nursesneeding schedule requests (i.e. continuing education). Theyunderstood that theirdecisions–whetherbigor small, impactthewholeunit.Participantsexpressedthatpatient-caredecisionswere considered themost crucial among the decisions. Theseinfluencetherelationshipamonghealthcaremembers(doctors,nurses, patients, and other health-allied professionals). Thisfindingwas supported by Ahmed and Safadiwho posited thatthe responsibility of making decisions influences patients andemployeesaswellastheirownactions[22].

Otherscenarioswhereintheneedforcollaborationwasevidentwerethroughsharingofideasandopinionandseekingadviceandhelpwhentheymakedecisions.Usually,astaffnurseconsultshisorherheadnursepriortoperformingprocedures.Consequently,theheadnurserespondsbyshowingsupportandassistancetothestaffnurse.

Job-sharingasemployedinthenursingunitnecessitatesgreatereffort forcollaboration.This ismostly truebecause thereweretwo head nurses to whom staff nurses interact with prior tomakingdecisions.Comparably,participantslearnedtheessenceof teamwork as they contribute to the knowledge and skillsneededbytheunitinperformingtasksandprocedure.Thisshouldemphasize that head nurses should foster a positive and safeenvironmentthatallowsforopenandrespectfulcommunicationwhichresultsintrust[50].

Nursemanagerswhoworkinajob-sharingset-upemphasizedtheimportanceofworkingin‘transparentdetermination’orknowingwhat isgoingon [20].Thisargument support the responsesoftheparticipantswhereintheyexpressedthatdecisions,whethermadeindependentlyorinterdependently,shouldbeknownandinformed.Endorsement,asoneofthenursingtasks,displaysthatcollaborationamongheadnursesand staffnurses is importantforthewholeteam.Itcannotbethataheadnurseiscompletelyunawareofwhatisgoing,whatdecisionshavebeenmade,andwhowereaffectedbythedecisions.

Job-sharing,asthetermimplies,involvesnotjustonepersonbuttwoormore.Inthiscontext,headnursesweresharingmanagerialroles and responsibilities. To concretize this in decision-makingaspect, staffnurseswereexpected to involve twoheadnursesastheymakedecisions.Asanexample,adecisionmadeduringher shifthasbeenderivedwith thehelpof theheadnurseonduty. Consequently, this would be endorsed to the incomingheadnursestomakesurethatactionsweremonitored.Thisevenfacilitated head nurse-doctor interaction because there weretimesthattheheadnurses’opinionissolicited.

Demands of the nursing profession require integration amongall levels. This is to encourage taking part into the practicesandcultureof theunit.Thispresent study isnot confined inausualheadnurse-staffnurserelationship.Thisinvolvestwoheadnurses,whomakedecisionswithin their level,andstaffnurses

whosharedecisionswiththeheadnursesaswell.Itemphasizedthatnoonecanbebypassedinthedecision-making.

Sharing decisions between head nurses also necessitatesintegration. This is usually observed when head nursesconsciouslymake effort to involve themselves in the decision-makingprocess.Atthesametime,itisimpliedtothemthatonecannotmakedecisionsrightawayespeciallywhenitwouldaffectbothofthem,thus,theinterdependence.

Theneed for integrationsets the foundation forandmaintainsthehelpingandsupportiverelationshipamongthemembers.Italsosteersmembersoftheunittobecomemoreparticipatory,hence, effective and efficient in providing health care to thepatients. Woodhouse et al. found that job-sharing provided astrongsenseofsupportforbothincumbentsoftheposition[33].Majorityoftheparticipantspreferredworkinginthistypeofset-upbecausetheyfeltasenseofaccomplishmentandsatisfactiontowardtheirwork.Staffnursesappreciatedhowhavingtwoheadnursesinfluencetheirprofessionandmaturity.

Summarily, staff nurses expressed that all needs describedwidened their horizons, developed their decision-makingskills and critical thinking, and enhanced their communicationstrategies.Headnurses,ontheonehand,conveyedthatshareddecisions and open and transparent communication increasedtheirknowledgeandimprovetheirleadershipskills.Theconceptneeds is the overall description of the decision-making andcommunication experiences of head nurses and staff nursesworkinginamanagerialjob-sharingset-up.

The Communication-Decision-making Matrix of Job-sharingisused to represent the themesemerging from the study.Theneedsidentifiedaretheeideticdescriptionofthephenomenon.It answers thecentralquestion“howdoheadnursesand staffnursesdescribetheirdecision-makingandcommunicationwhenjob-sharing is employed at the managerial level?” The needsaretheessenceoftheexperienceamongheadnursesandstaffnurses[51-71].

Conclusions and RecommendationsHeadnursesandstaffnurseslearnedthroughouttheirexperiencesthat there were needs arising from their communication anddecision-making experiences while working at the managerialjob-sharingset-up.Theseneedsfacilitatedtheirdailytransactionsspecifically in decision-making and communication. Theparticipantshaveunderstoodessentialingredientstoacquireandadapt for themtobecomeeffectivememberof theirunit. Thethemesidentifiedfromthedescriptionoftheirexperiencesentailtheneedsofjob-sharing.

The Communication-Decision-making Matrix of Job-sharingrepresentstheneedscomingfromthe job-sharingset-up.Eachneed ismetwhenthe factorsarepresent.Communicationanddecision-makingarethetwolayersofexperienceinthisqualitativeinquiry.Thecolumnshowingthe‘questionsasked’referstothecapturingquestionsoftheexperiences.Theresponseswerethefactorsneededtomeettheneeds.The‘resultingstates’arethedescriptions of the phenomenon. The ‘thematic descriptions’explain themeaningof thethemes.Thematrixshowsthat the



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needs do not necessarily transpire in chronological order toachieve certain goal or objective. No need is described to belowerorhigherovertheothers.

It is evident from the study that head nurses and staff nursesviewedjob-sharingasamanagementstrategywhichintegratedtheirknowledgeandskills inmakingdecisions,promotedopenandtransparentcommunication,andmaintainedaharmoniousworkingrelationship.Theneedsthatwereidentifiedtotranspireintheirday-to-dayroutinessteeredtheunittoperformeffectivelyupholding a supportive environment. It also negated thetraditionalconnotationofconflictsasdetrimentalordestructive.Itwasrecognizedasachallengewhichmustbeaddressedbytheparticipantsasateam.

This is one of the few studies to describe the views of headnursesandstaffnursesonthetwomostimportantprocessesinnursing–decision-makingandcommunication.Thenatureofthisqualitative investigation led to ensure credibility following theframeworkofGuba&LincolnascitedbyZhangandWildemuth[37]. Member checking was done by discussing the guidequestionswithparticipantspriortointerviewproperandfeedingtheideasbacktoparticipantstorefine,rephrase,andinterpret.

Asemi-structured interviewschedulewascarefullyconstructedthroughsupportoftheresearchsupervisortolessenthepotentialforanybias.Thestudy,asmightbeexpectedforastudyofthissize,hadanumberoflimitations.Firstly,becauseofthechosendesign,actualexperienceindecision-makingandcommunicationwerenotdirectlyobserved.Thetimeittookforthestudytobeaccomplished and frequency of the interviews also added upto the limitations. Lastly,given thenumberof theparticipants,futurestudiesmayincreasetostrengthengeneralizability.

Overall, the participants expressed the needs to be met indecision-making and communication aspects in job-sharing. Inaddition,theyarguedthatjob-sharingatthemanageriallevelissatisfactoryinthetypeoftheworktheyhaveasevidencedbythepositiveremarksandwantingtoretaintheset-upintheunit.Headnursesdidnotconveyanyformofcompetitionorrivalryinthepositionastheyholdindependenceintheiraccountabilitiesandresponsibilities.Meanwhile,staffnursesfavoredthepresenceoftwoheadnursesbecausetheyfeltconfidentthatthereisalwayssomeone to assist and support them in times of needswithintheirshift.Thus,theusualperceptionofonlyonepersonbeingabletoprovidethebestleadershipfortheunitwasdisprovedbythisstudy.

Staff nurses expressed their appreciation and satisfaction inhaving two head nurses. It was similar to having two parentswhomtheyknewtheycouldrelyon.Headnursesalsosupportedthispremiseastheyarticulatedtheeaseandcomfortofhavinga partner while they do stressful and challenging roles andresponsibilities.

Theauthorwishestorecommendjob-sharingasbotharetentionand recruitment strategy for nurses in the country. Since ourcountryfaceshighunemploymentandhighmigrationofskillednurses, job-sharingmay be considered as one of the solutionsas it offers the convenience of work-life balance; meeting thedemandsof familyandchildrenathome,whilegrowing in thecareerbothpersonallyandprofessionally.

Interestingly,thisqualitativeinvestigationconfirmsthatthereissomuch tounderstand indecision-makingandcommunicationamongnurses. Inaddition, itmayberecommendedtohospitaladministrators to adapt job-sharing arrangement to retain ourskilled professional nurses and to provide opportunity for thebeginningnursepractitionersbyemployingtheminajob-sharingset-up,maybeinamixtureofjob-sharingandjob-splitting.

Moreover,itisknownthatsomenursesatthemiddle-agewishtocontinuehighereducationwhilebeinghands-onparentstotheirchildren and caregivers to agingparents or relatives.With thisentiredilemma,nursesare likelytochooseoneovertheother.However,job-sharingminimizesthestressofthesituationsinceitcatersandadvocatesflexibleworkingarrangement,thus,work-lifebalance.Nurseswhoseekabetterbalancebetweenfamilylifeandcareerwithouthavingtobeemployedoutsidethecountryaremostsuitableinjob-sharingset-up.Job-sharingoffersamoreflexiblewayofaddressingtheneedsofusuallyabeginningfamilyandgrowingcareer.Despitethestress,challenges,anddemandsofamanagerialposition,headnursesmaybeabletofindawayto integrate their lifeandwork.Further, job-sharinghasahighpotentialtobecomeeffectivefornurseswhoarewillingtoworktogether and open for consultation and discussions with theirpartners.

Despiteoffewliteraturessuggestinghighercostforjob-sharing,this study supports others which argued otherwise. This isbecause job-sharing retains highly skilled and specialized headnurseswho can contribute to theprofessionaldevelopmentofbeginningnursesthroughmentoringandtraining.Recruitment,orientation, and training for newly hired (or external) headnursesareprovedtobemorecostlycomparedtoretainingheadnurses.Theneedsidentifiedfromcommunicationanddecision-makingaspectsmayserveasabasisforjob-sharingproceduresandpolicies.

Reasons for job-sharing are diverse. These may be congruentdependingontheneedsofanurse.Sincethisstudyinvestigatedonthe job-sharingasemployedat themanagerial level,careerdevelopment and enhancement are seen as few of themajoradvantages.Continuingfurthereducationorenjoyingwidearrayofknowledgeandskillsbroughtinbypartneringheadnursesisconsideredasareasonforengaginginjob-sharing.

On the one hand, it serves as a helpful tool in training andmentoring. A newly promoted, less experienced head nursemaylearnmanagerialskillsfromhermature,moreexperiencedpartner. Administratorsmay be able to cut down their budgetin special trainings intended for newly hires and allot it toother areas such as incentives for performances, resource andmaterialsneededbytheunit,orresearchgrantsforthehospitalemployees.

Job-sharing has been agreed to minimize burn-out especiallyon thepart of theheadnurses as it ease theburdenof beingresponsible for theunit all thetime. Job-sharers are confidentthat theirpartnerheadnurse is visible in theunit andprovidecoverage for each staff nursewhile they are away fromwork.In addition, it reduces the number of sick days as job-sharersare not exhausted despite the bulk of their duties. Continuity



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of supervision without passing the buck is also an observedadvantageofjob-sharingamongheadnurses.

Priortoemployingandengagingjob-sharingintheunit,partnerselectionmustbeexaminedcarefully–consideringalltheneedspresented in a job-sharing set-up. Determining demographicprofile, personality assessment, expertise and experienceevaluation are the keys to make a suitable and effectivepartnership.Althoughknowingthepartnerpersonallyisarguedtobenotsoimportant,itmaybebeneficialinsomeways.

Despite the advantages that job-sharing offers to themajority,carefulandkeenexaminationpriorto implementationmustbeemployed. Compatibility checking between job-sharers maybeoneof themost importantaspects tobeconsideredbeforesetting up employees in job-sharing. A pilot testing may behelpful forassessmentof thestrengthsandweaknesses itmayhave. Compatibility in communication styles is oneof the keysto successful job-sharing. It promotes exchange of ideas andconsultationrelatedtotheprogramsbeingimplementedintheunit.

Job-sharingnursesarebecomingmoreappreciatedastheyexerteffortandcontributionformeetingthegoalsandobjectivesoftheunit.Theirpartnershipmaybeseenasadedicationtotheirworkandcommitmentwiththeircolleagues.Opencommunicationislikelytobeobservedasjob-sharingrequiresinteractionbetweenjob-sharersandothermembersoftheteam.

Indeed, job-sharing nurses and hospital administrators mustalsowatchoutforthechallengesanddisadvantagesjob-sharingmay brought to the organization. Incompatibility is one of theproblemsthatmaybefeltduringtheearlystageofjob-sharing.Since it usually pairs up employees ready for the position, keyassessment areas such as compatibility checking is not greatlyobserved. Compatibility is seen overtime as two or moreindividuals interact and relate with each other as they worktogether.

Dividingtaskssuchasstaffing,deliverables,andinventorymaybeproblematicifonefeelsoverworkedorunderworked.Job-sharingpairsshouldbeclearwitheachotherhowtheyassigntasks.Oneof the simple actions made by job-sharers is the alternatingassignment of tasks and duties (i.e. monthly, quarterly). Inaddition, job-sharers must be aware of the potential for rolepossessiveness as they become experienced and familiar withthecultureoftheunit.

Sincetherewerenoevidencesinthelocalliteraturesthata‘third’headnursemightbeemployedfornightshifts,itisrecommendedforresearcherstoventuretheirinquiryinthissituation.Fornursemanagersandadministrators,developingamodelwhichinvolvesjob-sharingmaybeadvisable.

Arguably, the feasibility and success of job-sharing lies on themeeting the needs discussed earlier in this study. The needsidentifiedwithinthecommunicationanddecision-makingaspectsarousetheactiondirectedtowardachievingcommongoalsandobjectivesoftheunitandtheorganization.



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