Improve the satisfaction of medical staff on the use of home nursing mobile APP by using a hybrid multi-standard decision model.

OBJECTIVE: To identify critical satisfaction gaps in a home nursing mobile application (APP) using a systematic decision-making model. METHODS: Initially, the decision-making trial and evaluation laboratory method was used to analyze the relationship structure and corresponding weights among the indicators. The Importance-Performance Analysis (IPA) method was used to identify the categories of all indicators and their corresponding strategic directions. Twenty-six home nursing specialists currently providing home nursing services were recruited for this study. RESULTS: The IPA results revealed that "Assurance," "Reliability," and "Personal security protection" are critical satisfaction gaps. From the influence network and weight results, "information quality" and "system quality" were the critical quality factors in the home nursing mobile APP. The influence of the network relationship structure and weight demonstrated a 98.12% significance level, indicating good stability. CONCLUSION: Continuous improvement in information and system quality is recommended to optimize the overall quality of the home nursing mobile APP. Additionally, user demands should be considered, and personal safety guarantee functions should be developed and integrated into the system to ensure the safety of home nursing workers.

Importance-Performance Analysis of Clinical Forensic Services Quality at Bhayangkara Hospital Pekanbaru, Indonesia.

Background: Service quality improvement efforts must focus on the utilisation of resources for continuous quality improvement. The importance-performance analysis (IPA) method is useful in finding service quality items that require corrective action. This study implemented the IPA method to obtain items that should be prioritised in improving the quality of a hospital's clinical forensic services. Methods: A cross-sectional study of 284 clinical forensic patients at Bhayangkara Hospital, Pekanbaru, Indonesia was conducted. Self-administered and paper-based questionnaires, specifically the modified service quality (SERVQUAL)-based questionnaire, were used as the study instruments. Twenty-two service quality items were used as indicators and they were divided into five dimensions of service quality: i) reliability, ii) responsiveness, iii) assurance, iv) empathy and v) tangibility. The data were analysed using the IPA method. Results: The results showed that only seven items had a gap and a level of conformity that met the expectations of clinical forensic patients. Improvements in service quality should prioritise four items: i) providing a more private examination room for clinical forensic patients, ii) improving healthcare workers' understanding of patient needs, iii) improving the readiness of healthcare workers to conduct examinations and iv) enhancing the clarity of information about examination procedures. Conclusion: The IPA method yielded several high-priority items that need to be improved; therefore, the hospital must focus on improving the quality of clinical forensic services.

Identification of critical quality factors and critical satisfaction gaps in emergency training courses for new nurses by the multi-criteria network structure model.

OBJECTIVE: To identify critical quality factors and critical satisfaction gaps in emergency training courses for new nurses through a systematic decision-making model. METHODS: Firstly, the service quality (SERVQUAL) was used in the evaluation index system of this study. Then, the decision-making trial and evaluation laboratory (DEMATEL) method was used to analyze the relationship structure and the corresponding weights between the indicators. Finally, the importance-performance analysis (IPA) method was used to identify the categories of all indicators and the corresponding strategic directions. Fifteen new nurses in Taizhou Hospital of Zhejiang Province were selected as participants in this study. RESULTS: The IPA results showed that "(C13)," "(C22)," "(C52)," "(C53)," "(C54)," "(C55)," "(C56),"and "(C57)" are critical satisfaction gaps. From the results of influence network and weight, empathy (C5) was the critical quality factor of the entire training course. The influence network relationship structure and weight had a 98.1% significant confidence level, indicating good stability. CONCLUSION: Teachers' empathy is key to the learning outcomes of new nurses in emergency nursing training courses. Hence, teachers should be attentive to the empathetic quality of their teaching methods to help new nurses gain knowledge and experience in emergency care, especially when they come from different professions and departments.

Using hybrid consistent fuzzy preference relations-importance-performance analysis model to improve shared decision-making quality based on orthopaedic nurses' perceptions.

PURPOSE: To understand key factors for shared decision-making (SDM) and the quality improvement of nursing decisions in the orthopaedic clinical environment. METHOD: This study applied the consistent consistent fuzzy preference relations (CFPRs) and importance-performance analysis (IPA) methods to explore the attribute weights and SDM performance, respectively. The dataset was collected from 16 orthopaedic clinical nurses' experiences in a third-grade and first-level general hospital in Taizhou, China. This study was performed according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines. RESULTS: The results showed that "I made clear to my patient or patient's family that a nursing care decision needs to be made", "I explained the advantages and disadvantages of the nursing care options to my patient or patient's family" and "I told my patient or patient's family that there are different nursing care options for caring his/her medical condition" were key factors for affecting SDM. The statistical significance confidence and difference error of weight results were 98.321% and 1.679%, respectively. In addition, "I asked my patient or patient's family which nursing care option he/she prefers" was the key factor for improving orthopaedic clinical nursing in the case hospital. CONCLUSION: The hybrid CFPRs-IPA model can help hospital managers effectively understand the key factors of SDM quality and improve the orthopaedic clinical nursing performance from nurses' perspectives. RELEVANCE TO CLINICAL PRACTICE: A quantitative decision-making model can help nurses understand the key factors affecting the quality of SDM in nursing decision-making and promote nursing decision-making and patient-centred nursing service quality. A series of corresponding SDM training courses (i.e. concepts, knowledge and skills) can be provided for hospital and nursing department managers to maximise the potentially available resources. PATIENT OR PUBLIC CONTRIBUTION: The clinical care process should be committed to involving patients in their care decisions and also provide an opportunity for patients to gain a comprehensive understanding of the care decision-making process in order to inform future patient contributions to care decisions.

Nurses' perspectives of the patient care experience assessment items using importance-performance analysis.

AIM: This study aimed to evaluate the importance and performance of hospital nurses for patient experience evaluation items from the perspective of care providers and to identify the items that need improvement. BACKGROUND: Patient experience includes customized treatment and services that focus on patient satisfaction and needs, with healthcare providers participating as partners. METHODS: The study was conducted using a cross-sectional survey design, and data were collected on the importance and performance of 15 out of 24 patient experience evaluation items. The sample population consisted of 193 direct care nurses from two hospitals in South Korea. RESULTS: The results showed the items with significant differences in importance and performance ('concentrate here' areas) such as 'description of a drug' (t = 2.26, p = .025), 'listening to patients' (t = 6.64, p < .001), 'description of adverse drug reactions' (t = 10.19, p < .001), 'clean hospital environment' (t = 2.95, p = .004) and 'easy notification of complaints' (t = 8.37, p < .001). CONCLUSION: The findings highlight the importance of awareness and performance in patient experience evaluation items from the nurses' perspective. While some items were recognized as important but not performing well, others were identified as important and performing well. IMPLICATIONS FOR NURSING MANAGEMENT: As identified in this study, nursing managers should strive to develop nursing practice standards and educational programs for nurses to improve patient experiences. It is crucial that these changes are reflected in policies.

Consumers' perceived effectiveness of COVID-19 mitigation strategies in restaurants: What went well and what could we do better?

As restaurants are resuming normal operations, COVID-19 mitigation strategies are still in place. An effective COVID-19 mitigation protocol may facilitate a more successful rebound since consumers may perceive a lowered risk to purchase food from the restaurant with protocols in place. However, little is known regarding how consumers evaluate restaurants' present efforts to contain the transmission of COVID-19. By using a rigorous scale development procedure, this study creates a scale to measure restaurant consumers' perceptions of COVID-19 mitigation strategies (acronym: PHASE): Protective equipment/technology (P); Health and hygiene (H); Access of purchase/serving (A); Safety measure for customers (S); and Employee safety measure (E). The study further identifies the areas that need to be improved by using importance-performance analysis. Findings of this study provide guidelines for restaurant professionals to potentially reallocate their existing resources to refine their COVID-19 mitigation strategies and to better prepare for the future.

Saving the hotel industry: Strategic response to the COVID-19 pandemic, hotel selection analysis, and customer retention.

This study investigates the effect of the COVID-19 pandemic on the hotel selection attributes and customer post-purchase behaviors. Qualitative and quantitative processes comprising an importance-performance analysis are used. This mixed-methods approach successfully (1) explores the hotel selection attributes after the COVID-19 pandemic, (2) uncovers the change of importance of these attributes before and after the outbreak of COVID-19, (3) identifies the importance and the performance level of the hotel selection attributes, and (4) explores the roles of the hotel selection attributes that form the overall image of a hotel and the subsequent intentions to revisit a hotel. This study includes a high degree of value, and this is the first empirical research that explores the guests' hotel choice behaviors before and after the pandemic, which can be helpful for the subsequent guest-behavior studies in the post-pandemic era.

Doctor-patient relationship improved during COVID-19 pandemic, but weakness remains.

OBJECTIVE: To assess the quality of the doctor-patient relationship (DPR) in China and possible influencing factors during the COVID-19 period from the patient's perspective. METHODS: An online survey was carried out nationwide from March 12, 2020 to March 30, 2020 in China via a convenience sampling strategy. Patients who met the inclusion criteria were invited to complete a questionnaire regarding the quality of DPR, including sociodemographic information, the Patient-Doctor Relationship Questionnaire (PDRQ-9), and influencing factors for DPR during the pandemic. RESULTS: A total of 1903 patients were included. Our result showed that participants had a higher PDRQ-9 score during the COVID-19 pandemic (4.18 ± 0.51) than that before the COVID-19 pandemic (3.86 ± 0.67). Importance-performance analysis (IPA) revealed that doctor-patient communication, patient satisfaction, consultation time, doctor's attitude, and medical knowledge were specific aspects that needed to be prioritized to improve the DPR. Multiple linear regression analysis suggested that positive media reports, telemedicine, and national policies had a significantly positive effect on the DPR during the pandemic (P < 0.05). CONCLUSION: In general, the DPR had been improved during the COVID-19 pandemic. Our research found the key points that needed to be prioritized to improve the DPR during the pandemic, which may provide effective suggestions for building a harmonious DPR in the future.

Operating room nurses' perceptions of the impact of surgical smoke and its countermeasures: A mixed-methods study.

Although surgical team members are exposed to surgical smoke, most do not fully recognize the hazards of such exposure during surgery. This study aimed to explore the perceptions of surgical smoke and its countermeasures in the operating room, specifically among nurses who have been exposed to surgical smoke for a long time. This was a mixed-methods study involving focus groups and a descriptive survey. The focus group revealed that nurses believed harmful substances accumulating in the body were proportional to the years worked, and many were unaware of the existent hazards in their work environment. They encouraged the formulation of self-protection measures and perceived that the recognition of rules and collaboration should take precedence among potential countermeasures. Our survey showed that properly wearing personal protective equipment and being educated on surgical smoke hazards were identified as essential coping methods for nurses. These findings will help create awareness regarding surgical smoke hazards in operating rooms. Policies and systems need to be established at the hospital administration level to substantially reduce the risks associated with surgical smoke for operating room nurses.

Dealing with pandemics: An investigation of the effects of COVID-19 on customers' evaluations of hospitality services.

The hospitality industry is highly vulnerable to pandemics. However, little is known about how pandemics alter travelers' evaluations of hospitality services. Therefore, this study investigates the changes in travelers' expectations and perceptions of hotel services during different stages of the novel coronavirus 2019 (COVID-19) pandemic. 98,163 Chinese hotel reviews were collected and scrutinized via text mining and sentiment analysis techniques to derive new implications for service optimization. The results reveal shifts in consumers' evaluations well beyond hygienic requirements. Insights obtained from this research can help guide hospitality practice in organizing its priorities during acute pandemic situations and adjusting to possibly longer-lasting shifts in consumer preferences.

Mixed methods research on satisfaction with basic medical insurance for urban and rural residents in China.

BACKGROUND: There have been few studies on satisfaction with integrated basic medical insurance for urban and rural residents (URRBMI), and satisfaction with URRBMI is not very high because of the complexity of its policies and differences among the insured. The aim of the present study was to explore the factors that influence satisfaction with URRBMI in China and to provide scientific suggestions to the government for how to effectively manage and improve the policy. METHODS: An explanatory sequential design of mixed methods research was used. A quantitative research using a three-stage stratified cluster sampling method was used to randomly select the guardians of pupils who participated in URRBMI (n = 1335). The quantitative research was conducted to calculate the latent variables' scores and path coefficients between latent variables using SmartPLS3.0. With public trust, public satisfaction, and perceived quality as the target variables, important-performance analysis (IPA) was used to explore the important but underperforming factors, which were the key elements to improving satisfaction with URRBMI. A purposeful sampling strategy according to satisfaction level was used to obtain qualitative research subjects from among the quantitative research subjects. A qualitative research was conducted using semi-structured interviews, and the thematic analysis method was used to summarize the interview data. RESULTS: The three strongest paths were perceived quality to public satisfaction, with a total effect of 0.737 (t = 41.270, P < 0.001); perceived quality to perceived value, with a total effect of 0.676 (t = 31.964, P < 0.001); and public satisfaction to public trust, with a total effect of 0.634 (t = 31.305, P < 0.001). IPA revealed that public satisfaction and perceived quality were key factors for public trust and that perceived quality was of high importance for public satisfaction but had low performance. The policy quality was a determining factor for perceived quality. The qualitative research results showed that the most unsatisfactory aspect for the insured was the policy quality. CONCLUSIONS: This study found that improving quality is key to improving public satisfaction with and public trust in URRBMI. The government should improve the compensation level by broadening the channel of financing for the URRBMI fund, rationally formulating reimbursement standards, and broadening the scope of the drug catalog and the medical treatment projects. The government should establish a stable financing growth mechanism and effective methods of providing health education to improve public satisfaction and public trust.

Consumption Patterns and Importance-Performance Analysis of Home Meal Replacements by Level of Taurine-Related Nutritional Knowledge in Korean Adults.

The purpose of this study was to investigate consumption patterns and perform Importance-Performance Analysis (IPA) of selective attributes of Home Meal Replacement (HMR) products according to taurine-related nutritional knowledge levels in Koreans aged 40-64 years as a basis for developing additional HMR products. The study included 793 adults (297 males and 496 females) who had experience in consuming HMR products and who lived in Seoul and its metropolitan areas, Korea. Data were collected using self-administered questionnaires. Statistical analysis was performed by using the SPSS 18.0 program. The subjects were classified into a high-level group (HG, 467 adults) and low-level group (LG, 326 adults) based on their taurine-related nutritional knowledge scores. Analysis of HMR consumption patterns showed that the frequency of HMR consumption in the HG was one to two times a month in 41.1% of the subjects and once every 3-4 months in 22.7% of the subjects, whereas, in the LG, it was one to two times a month in 39.3% of the subjects and four to six times a month in 24.5% of the subjects. With regarding to the reasons for purchasing HMR products, there was no significant difference between HG and LG (p = 0.089). The IPA analysis of HMR selective attributes included factor analysis of 14 selective attributes that were divided into three factors: 'convenience and taste', 'reliability and health', and 'brand and awareness'. The average importance scores of the first (p < 0.01), second (p < 0.001), and third (p < 0.01) factors in the HG were significantly higher than those in the LG. In addition, the average satisfaction with the first factor (p < 0.01) in the HG was significantly higher than that in the LG. Based on the IPA results, the selective attributes with low satisfaction and high importance were price, origin, food additives, and nutrient content in both the HG and LG. In the second IPA quadrant was safety, but only in the LG. Multiple regression analysis revealed that the importance of the reliability and health factor and the satisfaction with the convenience and taste factor were positively influenced by the subject's taurine-related nutritional knowledge score. These results suggest that reliability and safety of HMR products need to be improved to meet the expectations of Korean consumers aged 40 years and older with a high level of taurine-related nutritional knowledge. Therefore, there is a need to produce HMR products that use safe and reliable food ingredients.

Recommended care received by geriatric hip fracture patients: where are we now and where are we heading?

INTRODUCTION: Despite the availability of clinical guidelines on the prevention and treatment of geriatric hip fractures, the percentage of recommended care received by patients is low. We conducted an importance-performance analysis for prioritizing interventions to improve the in-hospital management of these patients. MATERIALS AND METHODS: A secondary data analysis was conducted on the in-hospital treatment of 540 geriatric hip fracture patients in 34 hospitals in Belgium, Italy, and Portugal. First, we assessed the level of expert consensus on the process indicators composing international guidelines on hip fracture treatment. Second, guideline adherence on in-hospital care was evaluated within and across hospitals. Third, an importance-performance analysis was conducted, linking expert consensus to guideline adherence. RESULTS: Level of expert consensus was high (above 75%) for 12 of 22 process indicators identified from the literature. There is large between and within hospital variation in guideline adherence for these indicators and for none of the 540 patients were all 22 process indicators adhered to. Importance-performance analysis demonstrated that three indicators that had a high level of expert consensus also had a high level of adherence (above 80%). Nine indicators, most of which have been previously linked to patient outcomes, had a high level of expert consensus but a consistently low level of adherence across hospitals and are identified as priority areas for improvement. CONCLUSIONS: Guideline adherence for the treatment of geriatric hip fracture patients is remarkably suboptimal. Importance-performance analysis is a useful strategic approach to assist practitioners and healthcare managers to improve the quality of care.

Needs assessment survey for simulation-based training for gastrointestinal endoscopy nurses.

The optimal performance of gastrointestinal (GI) endoscopy nurses is required for patient safety and quality improvement. The aim of the present study was to assess the educational needs for simulation-based training for Korean GI endoscopy nurses using importance-performance analysis. A cross-sectional survey was conducted with 238 Korean nurses from 25 endoscopy units. The educational needs of these nurses were identified using the 35 item clinical competence importance-performance scale. Exploratory factor analysis of the scale identified the following eight factors: emergency care, patient monitoring, evidence-based practice, documentation and referral, patient safety, nursing process, patient assessment, and infection control. A significant overall mean difference was identified between importance and performance for all eight factors, with emergency care showing the largest difference. It was also ranked the highest priority for continuing education in the importance-performance analysis matrix. Therefore, simulation-based training should focus on enhancing emergency care competence for GI endoscopy nurses to improve patient safety and quality of care.

Variation in care for surgical patients with colorectal cancer: protocol adherence in 12 European hospitals.

PURPOSE: Surgical care for patients with colorectal cancer has become increasingly standardized. The Enhanced Recovery After Surgery (ERAS) protocol is a widely accepted structured care method to improve postoperative outcomes of patients after surgery. Despite growing evidence of effectiveness, adherence to the protocol remains challenging in practice. This study was designed to assess the adherence rate in daily practice and examine the relationship between the importance of interventions and adherence rate. METHODS: This international observational, cross-sectional multicenter study was performed in 12 hospitals in four European countries. Patients were included from January 1, 2014. Data was retrospectively collected from the patient record by the local study coordinator. RESULTS: A total of 230 patients were included in the study. Protocol adherence was analyzed for both the individual interventions and on patient level. The interventions with the highest adherence were antibiotic prophylaxis (95%), thromboprophylaxis (87%), and measuring body weight at admission (87%). Interventions with the lowest adherence were early mobilization-walking and sitting (9 and 6%, respectively). The adherence ranged between 16 and 75%, with an average of 44%. CONCLUSION: Our results show that the average protocol adherence in clinical practice is 44%. The variation on patient and hospital level is considerable. Only in one patient the adherence rate was >70%. In total, 30% of patients received 50% or more of the key interventions. A solid implementation strategy seems to be needed to improve the uptake of the ERAS pathway. The importance-performance matrix can help in prioritizing the areas for improvement.

An International Study of Adherence to Guidelines for Patients Hospitalised with a COPD Exacerbation.

Guideline adherence rates for the treatment of chronic obstructive pulmonary disease (COPD) exacerbation are low. The aim of this study is to perform an importance-performance analysis as an approach for prioritisation of interventions by linking guidelines adherence rates to expert consensus rates for the in-hospital management of COPD exacerbation. We illustrate the relevance of such approach by describing variation in guideline adherence across indicators and hospitals. A secondary data analysis of patients with an acute COPD exacerbation admitted to Belgian, Italian and Portuguese hospitals was performed. Twenty-one process indicators were used to describe adherence to guidelines from patient record reviews. Expert consensus on the importance for follow-up of these 21 indicators was derived from a previous Delphi study. Three of the twenty-one indicators had high level of expert consensus and a high level of adherence. Eleven of the twenty-one indicators had high level of expert consensus but a low level of adherence. For none of the 378 patients included in this study were all process indicators adhered to, patients received 41.0% of the recommended care on average, and only 34.1% of the patients received 50% or more of the care they should receive. There was also a large variation within and between hospitals regarding the care received. This study confirms the findings of previous studies, indicating that COPD exacerbations are largely undertreated. Importance-performance analysis provides a decision-making tool for prioritising indicators. All hospitals in this study would benefit from having in place a quality framework for systematic follow-up of these indicators.

Evaluating health service quality: using importance performance analysis.

Purpose Measuring healthcare service quality provides an objective guide for managers and policy makers to improve their services and patient satisfaction. Consequently, the purpose of this paper is to measure service quality provided to surgical and medical inpatients at Kerman Medical Sciences University (KUMS) in 2015. Design/methodology/approach A descriptive-analytic study, using a cross-sectional method in the KUMS training hospitals, was implemented between October 2 and March 15, 2015. Using stratified random sampling, 268 patients were selected. Data were collected using an importance-performance analysis (IPA) questionnaire, which measures current performance and determines each item's importance from the patients' perspectives. These data indicate overall satisfaction and appropriate practical strategies for managers to plan accordingly. Findings Findings revealed a significant gap between service importance and performance. From the patients' viewpoint, tangibility was the highest priority (mean=3.54), while reliability was given the highest performance (mean=3.02). The least important and lowest performance level was social accountability (mean=1.91 and 1.98, respectively). Practical implications Healthcare managers should focus on patient viewpoints and apply patient comments to solve problems, improve service quality and patient satisfaction. Originality/value The authors applied an IPA questionnaire to measure service quality provided to surgical and medical ward patients. This method identifies and corrects service quality shortcomings and improving service recipient perceptions.

Status of cardiopulmonary resuscitation curricula for nursing students: A questionnaire study.

In this study, we explored the status of curricula for nursing students and identified the priorities for curricula improvement using importance-performance analysis. A cross-sectional, descriptive survey was conducted, which included 62 instructors in charge of resuscitation training. The participants completed the self-administered, 32-item Resuscitation Curricula Attributes Importance-Performance Scale. With Wilcoxon signed-rank test, an importance-performance analysis matrix was created. There was a significant overall mean difference between importance and performance in all 32 items, with "recognition of arrest rhythms" showing the largest difference. Importance-performance analysis suggests that the priorities for improvement are "nursing record documentation" and "recognition of arrest rhythms". The development of cardiopulmonary resuscitation curricula should focus on attributes that are expected of practitioners and are relevant to current healthcare environment needs.

Applying importance-performance analysis to patient safety culture.

PURPOSE: The Sexton et al.'s (2006) safety attitudes questionnaire (SAQ) has been widely used to assess staff's attitudes towards patient safety in healthcare organizations. However, to date there have been few studies that discuss the perceptions of patient safety both from hospital staff and upper management. The purpose of this paper is to improve and to develop better strategies regarding patient safety in healthcare organizations. DESIGN/METHODOLOGY/APPROACH: The Chinese version of SAQ based on the Taiwan Joint Commission on Hospital Accreditation is used to evaluate the perceptions of hospital staff. The current study then lies in applying importance-performance analysis technique to identify the major strengths and weaknesses of the safety culture. FINDINGS: The results show that teamwork climate, safety climate, job satisfaction, stress recognition and working conditions are major strengths and should be maintained in order to provide a better patient safety culture. On the contrary, perceptions of management and hospital handoffs and transitions are important weaknesses and should be improved immediately. Research limitations/implications - The research is restricted in generalizability. The assessment of hospital staff in patient safety culture is physicians and registered nurses. It would be interesting to further evaluate other staff's (e.g. technicians, pharmacists and others) opinions regarding patient safety culture in the hospital. ORIGINALITY/VALUE: Few studies have clearly evaluated the perceptions of healthcare organization management regarding patient safety culture. Healthcare managers enable to take more effective actions to improve the level of patient safety by investigating key characteristics (either strengths or weaknesses) that healthcare organizations should focus on.

Importance and performance of managerial skills in the Australian aged care sector - a middle managers' perspective.

AIM: This study examined the importance and performance of middle managers' skills to provide a starting point for a sector-wide leadership and management framework. BACKGROUND: There is an increasing consensus that the quality of management, leadership and performance of any organisation is directly linked to the capabilities of its middle managers and the preparation and on-going training they receive. METHOD: A total of 199 middle managers from three aged care organisations in Australia participated in a questionnaire conducted during 2010-2011. RESULT: This study found that middle managers perceived the need to develop their communication skills, self-awareness, change management, conflict resolution and leadership skills. CONCLUSION: Middle managers perceive a discrepancy between performance and importance of various managerial skills. This study demonstrated that provision of training needs to go beyond clinical skills development and further investigation into managers' needs is necessary, particularly considering the diversity of this critical group in organisations. IMPLICATIONS FOR NURSING MANAGEMENT: Future training opportunities provided to middle managers need to address the 'softer' skills (e.g. communication) rather than 'technical' skills (e.g. clinical skills). The provision of training in these skills may improve their performance, which may also lead to increased job satisfaction, continuity in leadership and management and ultimately improvements in the quality of care provided.