The research methodology was divided into three main phases using mixed methods, commencing with literature review to identify the initial framework about managerial competences. Focus groups were then used to discuss evidence from the literature. Feedback from focus groups was used to draft the final questionnaire. Finally, the answers to the questionnaire were analysed through statistical software.
Health service research includes investigation of complex processes and systems, and may necessitate both qualitative and quantitative forms of data [31]. Furthermore, mixed method research studies draw upon the strengths of both qualitative and quantitative approach. In our study, qualitative methodology is applied to explore the vast world of managerial competences and to identify the key concepts; and these findings are then measured in an online survey quantitatively. This methodology was used in previous studies [32], and Fetters and colleagues define it as “exploratory sequential design” [31].
A systematic review of the literature
First of all, a Systematic Literature Review (SLR) was carried out to define the domains of managerial competences in the healthcare sector (topics). We followed the approach used by David and Han [33] and Newbert [34]. The databases used were Scopus and Ebsco Host. We limited the search period to 1985-2017. This period was selected because clinicians started to be increasingly involved in the management of healthcare organisations in the second half of the 1980s [35]. The keywords applied as filters were: (“managerial competence” OR “managerial skill*” AND health*); (“clinical manager” OR “doctor manager” OR manager-clinician OR manager-physician AND competence OR skill*). We deleted duplicate articles from the search, performed on two different databases, and we read abstracts of the remaining papers. In this step, two researchers independently assessed the relevance of the articles for our aim. The articles were read in their entirety, and those that proposed a systematic categorisation of competences were selected for our research.
Focus group and questionnaire
In the second step, the research was conducted through a focus group discussion (FGD). The aim of the FGD was to gather collective views on the topics of competences for healthcare management in order to identify the specific managerial competences for each topic. Ten healthcare management educators were invited to a single location to participate in the FGD. The participants were selected from a group of people who have skills and experience in the field. The FGD was conducted in March 2018. During the FGD, participants were given the list of the topics emerging from the SLR. Within each topic, participants were asked to identify the specific competences required of the manager-clinician. Each participant noted the specific competences for each topic on a piece of paper, and then all competences were written up on a whiteboard to be shared and discussed. The discussions above each topic and each specific competence were moderated by one of the researchers, recorded, transcribed verbatim, and analysed using templates. Over seven hours of discussions were conducted. The main managerial competences emerging from the FGD were used to define the key items of the questionnaire (see Additional files). Moreover, in each topic, we grouped the managerial competences into two sections according to how each competence is used in practice. These sections were also discussed and shared by participants from focus group.
Survey and quantitative analysis
Finally, the questionnaire was administered online to about 1,500 healthcare workers in Italy over a period of six months (April 2018 - September 2018).
All survey recipients work in public healthcare organisations. Before sending, the questionnaire was subjected to a pilot test to verify the clarity of the questions. Three CEO of three large public hospitals were involved in the pilot test. The research focused on those working in different positions (physicians, nurses, veterinarians, psychologists, etc.) both with and without a managerial role. Therefore, those who have a managerial role also have a clinical background. The distinction between organisation role with managerial function (manager) and organisational role without managerial function (professional) reveals if and how position influences the perception of key competences, given that the perspective of the respondent is parallel with the position they fill. In the healthcare sector, previous research has already highlighted the need to analyse data by distinguishing between managers and non-managers [14, 36].
In addition to position held, the questionnaire investigates specific managerial competences for each topic. Each respondent was asked to identify the most relevant item; in other words, the specific competence considered most important for healthcare professionals filling a managerial role was identified. The results of the survey were elaborated and presented in two parts, each with a defined goal.
In the first part, the focus is on the items most and least frequently chosen. The aim is to identify those specific competences perceived as being most relevant and those that are perceived as being least relevant. There is also a comparison between responses from managers and responses from professionals. In the second part, the focus shifts to analysing the sections for each topic. The aim is to verify for each topic how the competences should be used in practice. There is also a comparison between managers and professionals.
Data from the questionnaire were processed using IBM SPSS Statistics V25.0.
In order to identify statistically significant differences between groups (managers vs professionals), the Pearson’s chi-squared test was run using a 5% significance level (p-value ≤ 0.05). To evaluate the intensity of the relationship we used the Phi index, when both variables were dichotomous (manager/professional vs sections), and Cramer’s V, when only one of the two variables was dichotomous (manager/professional vs items). We used the categorisation proposed by Dancey and Reidy [37] to classify the strength of the association: “weak” with a Phi index (or Cramer’s V) between 0.1 and 0.3, “moderate” between 0.4 and 0.6 and “strong” between 0.7 and 0.9.
Ethical approval
The present study was not submitted to an institutional ethics committee since it is not required according to Italian laws and legislation. The need for ethics approval is deemed unnecessary according to national regulations (Law no. 3, 11st January 2018).
All survey respondents gave their written consent to participate after being informed about the study.