Health Science Journal

Keywords

Job-sharing; Decision-making; Communication; Head nurses; Staff nurses; Communication–decision-making matrix of job-sharing

Introduction

Job-sharing in nursing has been identified as a useful strategy to retain and empower employees [1], to improve their job satisfaction and physical health status [2], and to improve worklife balance [3]. Numerous professions have embraced the practice of job-sharing making it popular among teachers and educators [4,5], pharmacists [6], and entrepreneurs [7].

Job-sharing, as a type of flexible working arrangement, has gained attention once again in research due to issues in the nursing profession such as nurse retention, nurse shortage, and job satisfaction [8]. Arising from the needs, issues, and demands of the nursing profession are the nurse manager shortage [1,9], recruitment and retention of nurse managers [10], nurse turnover [2], and aging nursing workforce [11,12], which, yielded to numerous innovations. One among the list of considerable changes is the working arrangements, especially in the industrialized countries. These suggested greater variation and flexibility in how, when, and where people work [3]. Interestingly, several advantages of job-sharing have been cited among literatures. It primarily allows more flexibility [6], employee worklife balance [3], improved family life [13], and pursuit of higher education [5,6,14,15], averred that reduced stress levels among key leaders makes shared leadership attractive since it does not burden any single leader.

Although literatures suggest that job-sharing has advantages and benefits in nursing [16], there are some that have argued otherwise. Job-sharing, like other strategies in management, has also its complexities and challenges. It was demonstrated in the study of Cathmoir, Mullooly, Brewer & Miller that work situations like job-sharing has a potential for role conflicts, possessiveness, and misunderstanding of role boundaries [17]. Resistance to jobsharing makes the implementation a challenging step [5].

Further, studies increasingly suggest that in any profession or industry, no single person can be perfect and right all the time to manage an organization, thus the draw for job-sharing. Kocolowski cited O’Toole, Galbraith, and Lawler that it is becoming a challenge for a single individual to possess skills and abilities required to competently lead an institution [5]. In addition, it has been highly recommended that the personalities of the jobsharers must be compatible [4,18,19].

Due to the advantages it offers to different professions, nursing has started to adapt this set-up particularly at the managerial level. Known to be a challenging and difficult role, job-sharing aids the managers to perform their tasks and responsibilities efficiently, increasing visibility and coverage in the unit, and integrating work and life. However, there is a dearth of literature on the nurse managers’ own experiences of partner leadership [20]. Concepts such as decision-making, communication, accountabilities, role boundaries, and competition are just few of the aspects that are not quite understood across literatures when job-sharing is employed at the managerial level [15,19].

Decision-making is considered one of the most important processes in management; and selecting the type and method of decision-making is considered to be one of the most important skills of a manager [21,22]. It is a multi-factorial process considering the complexities of clinical environment; a complex and cognitive course that is defined as choosing a particular course of action [22]. However, the process of decision-making is not quite understood especially in the context of nursing [23]. Head nurses and staff nurses are expected to share decisions as they work together in the unit. The dynamics and the process are much unclear when job-sharing is employed at the managerial level. Hoffman, Aitken, and Duffield argued that there are conflicts in the findings on the decision-making processes among nurses from different competency levels (i.e. novice and experts) [23].

Further, staff nurses are not exempted in playing a role in decision-making; they are stimulated or encouraged to engage in the process [24] and majority of decision-making is made by the staff nurses [25]. These arguments pose another issue in the decision-making especially in the context of job-sharing. This is because there are two or more head nurses that staff nurses share the decisions with rather than the traditional one of having single head nurse in a unit.

In addition, decision-making is becoming a transactional process not only between a head nurse and staff nurses but also between two head nurses. Similarly, leadership skills of the head nurses, in one way or another, may impact the decision-making process of the employees involved. In the study of Gunnarsson and Stomberg, the results highlighted the complexities of leadership required in decision-making [26].

Despite a rich heritage of rational approaches to understanding decision-making in the nursing literature [27] Thompson, Aitken, Doran, and Dowding argued that there are still key empirical and theoretical questions that remain unanswered in decisionmaking [28]. Thus, it is clearer that management strategies or leadership skills influence the decision-making process. However, little is known about decision-making aspects when the job is being shared by two or more managers. In a study by Harding and Sque, they argued that there is no research that explores the relationship and whether or not leadership impacts the decisions made by nurses in senior clinical positions, specifically, ward managers [29]. Further, only the positive effects and benefits of nurses’ involvement in decision-making were given attention [30]. Concomitantly, employees have the impression that they can actively shape the decisions in their organization [31]. Since scenarios may be completely different when job-sharing is employed at the managerial level, this present study seeks to describe the phenomenon of decision-making. A qualitative approach was utilized in this study since evidence of decisionmaking is observable only in actions performed by the decisionmaker, making it difficult to measure with quantitative methods [27].

Apart from decision-making, communication plays a key role in any organizational levels or any given workplace. Creedle et al. argued that communication is one of the most vital components to create success in a job-sharing venture [32]. Communication in a job-sharing environment may be an issue since it can draw splits [33] in a relationship between two partner managers and among staff nurses. In the study of Creedle et al., findings revealed that regardless of the overall satisfaction of the staff to managerial job-sharing, they felt that they did not like having to communicate issues perceived as sensitive to both of the managers, if their primary relationship is to only one of the managers [32].

It is unclear how communication takes place most especially when issues are highly sensitive and when one is uncomfortable dealing with both managers. In contrast, in a quantitative study by Acorn, Williams, Dempster, Provost, and McEwan, staff nurses were satisfied if they feel the open flow of communication between two managers [34]. These findings draw a blindspot on the aspects of communication when job-sharing is employed at the managerial level.

Methodology

Phenomenological design

This study is anchored by phenomenological design, qualitative approach. Phenomenology describes the meaning for several individuals of their lived experiences or a phenomenon. The lived experience itself, as described by participants, is used to provide universal description of the phenomenon [19]. The design of this study is laid upon the descriptive perspective, setting aside questions of any relationship of the phenomenon to the universe.

This study acknowledged that there is a gap in understanding of decision-making and communication aspects at the managerial set-up among nurses; and that description of experiences of the nurses will benefitthe nursing management and practice.

Setting and participants

The locus of the study was a 200-bed capacity, tertiary, government hospital in Metro Manila catering to non-contagious/ non-communicable diseases (https://www.jrmmc.gov.ph). It serves as a training hospital for students and professionals from various health and science fields coming from different cities and provinces of the Philippines. Specifically, the study took place in two, separate medical-surgical units where job-sharing is practiced by the head nurses. The position still remained as fulltime wherein each head nurse worked full 8-hour shift and shared overall responsibilities and accountabilities as a pair. The hospital employs this work arrangement primarily in departments with higher census of patients and higher number of nursing and nonnursing personnel.

The study involved two participant cohorts – head nurses and staff nurses (Table 1). Each cohort has a unique set of inclusion and exclusion criteria. Head nurses who participated in the study were those who (a) engaged in a job-sharing role with the same partner head nurse for at least six months, (b) have had jobsharing experience at the managerial level for at least a year, (c) have had managerial experience for at least five years, (d) age 30-60 years old, and (e) either male or female. Staff nurses who took part in the study were those who were (a) working at a unit wherein job-sharing set up is employed, (b) working for at least six months in a unit where eligible head nurses were assigned (c) working as a staff nurse for at least one year, and (d) 20-50 years old, and (e) either male or female.

Table 1: Participants’ Demographic Profile.

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	BS Nursing	Staff nurse	1-2+	1-2+	Pay Ward 2
02-JEE	<30	Female	Single	BS Nursing	Staff nurse	3-4+	3-4+	Pay Ward 1
03-CFC	30-45	Female	Married	BS Nursing	Head nurse	5-9+	5-9+	Pay Ward 1
04-GTL	<30	Male	Single	BS Nursing	Staff nurse	3-4+	1-2+	Pay Ward 2
05-JTV	30-45	Female	Married	BS Nursing	Head nurse	5-9+	5-9+	Pay Ward 2
6-Apr	<30	Female	Single	BS Nursing	Staff nurse	3-4+	3-4+	Pay Ward 2
07-AMI	30-45	Female	Married	BS Nursing	Head nurse	5-9+	3-4+	Pay Ward 1
08-CDP	<30	Female	Single	BS Nursing	Staff nurse	3-4+	3-4+	Pay Ward 1
09-RTG	<30	Male	Single	BS Nursing	Staff nurse	1-2+	1-2+	Pay Ward 1
10-JTD	<30	Female	Single	BS Nursing	Staff nurse	5-9+	1-2+	Pay Ward 1
11-FDR	30-45	Female	Married	BS Nursing	Head nurse	5-9+	1-2+	Pay Ward 2
12-GBC	<30	Female	Single	BS Nursing	Staff nurse	3-4+	3-4+	Pay Ward 2

A total of twelve participants (head nurse n=4, staff nurse n=8) from two different units were recruited as participants in the study. Selection of participants followed a purposive sampling wherein the researcher selected the individuals for study based on the knowledge of a phenomenon for the purpose of sharing the experience.

Instrumentation

This study utilized semi-structured interview with supplementation of protocol writing. Semi-structured interview encourages the participants to share their thoughts, experiences, and feelings which the researcher analyzes and interprets.

Data gathering

Upon signing of informed consent, participants were asked to answer a sheet (devised for each cohort) inquiring for their demographic information. The study utilized a two-part approach of data collection – protocol writing and semi-structured interview. Through protocol writing, the participants were asked to answer situational questions related to their decision-making and communication experiences. Participants were given ample time to answer the questions and were provided with spaces on the questionnaire for writing.

Subsequently, a conversational-style, semi-structured interviews (30 – 60 min) commenced. The interview was guided by the five descriptive questions which were concerned with decisionmaking and communication aspects allowing the participants to freely express their experiences with the researcher.

Ethical considerations

Informed consent was obtained from the participants by explaining first the aim of the study and the details of their participation. Each participant was given a copy of signed informed consent form. Permission to audio-record the interview was sought after ensuring confidentiality. Emphasis on the voluntary participation and the right to withdraw at anytime on the course of the study was upheld prior to data collection. Participants were assured that their identity would be kept in private through the use of alpha-numeric codes and password-protected media. Permit to conduct the study and ethical approval were sought since the study involved human interaction.

Mode of analysis

Anchored by the descriptive phenomenological design, descriptions of decision-making and communication experiences among staff nurses and head nurses were explicated following the Colaizzi’s mode of analysis (Table 2).

Table 2: Colaizzi’s mode of analysis.

Steps	Procedures
First	Reading and re-reading each transcript until obtaining the general sense
Second	Extracting significant statements from each transcript
Third	Formulating meanings from the significant statements
Fourth	Sorting the meanings into categories, clusters of themes, and themes;
Fifth	Integrating the findings into an exhaustive description of   the phenomenon
Sixth	Describing the fundamental structure of the phenomenon (research simulacrum)
Seventh	Validating the findings from the research participants to compare the researcher's descriptive results with their experiences.

The responses from protocol writing were merged with the semi-structured interviews transcriptions. The thematic analysis (Table 3) included the finding of significant and manifest ideas within the transcripts and grouping them into categories before reducing the texts into smaller coded units [35,36]. This process repeated many times which led towards further abstraction and resulted in six major themes as represented by a matrix (Table 4). Translation of the responses and verbatim in English language was carried out by an English language expert side by side with the formulation of themes. This facilitated the textural descriptions of the experiences in the study. The translations were then encoded opposite the original texts to observe for congruency with the descriptive texts. Dendrogramming was used to organize the meaning units into categories, clusters of themes, and themes.

Table 3: Results of Thematic Analysis.

Theme	Sub-themes	Descriptions
1. Need for identification	Triad of identities: Expertise, experience, and personality Strict versus lax; defender and the not	Head nurses have three aspects to relate their identities to – expertise, experience, and personality Expertise or forte, may be attributed to specialized knowledge or skills in a specific area (i.e. medical-surgical, intensive care) Experiences are the knowledge and skills gained from exposure in different events or scenarios which may be applied in the future Personalities are the collection of emotions and attitude reflected by the head nurses’ actions as perceived by co-head nurse and staff nurses Head nurses are being referred to being strict or lax. Strictness means acting in close conformity or set of principles, while laxness is not being strict enough, tense, or rigid Identification is the act of finding who is who; or the assumption of who a person is
2. Need for compatibility	Adjusting to differences (i.e. personalities) Blending with (dealing through informal conversations) Compatibility (achieved through adjustment and blending)	Knowing that there are differences, one should be able to adjust, as part of working relationship Staff nurses and head nurses learn how to adjust with the differences as they work together; both parties have the opportunity to work with each other; they check for the right timing when to open certain concern; test the waters by being sensitive to cues or mood Staff nurses make effort to blend in by informal conversation and injecting humor Compatibility is a valuable product of adjustment and blending which creates stronger bond between job-sharers. It appreciates the complementary shades of two different head nurses, rather than highlighting contrast of identities It means being able to exist and perform together without having to change
3. Need for belongingness	Togetherness and relatedness	Togetherness is a state of being close to another head nurse, creating harmony, strengthening partnership. Relatedness refers to being connected or finding common ground. Head nurses share similarities such as being both females, belonging to same generation group, tenure in the organization, within the same range of length of experience as head nurses. Belongingness is the feeling of becoming a part of a group or team; it is empowered by togetherness and relatedness
4. Need for negotiation	Consulting with supervisor or to institutional policies Consensus Challenges; conflict and confusion	Consulting with supervisor when issues are not manageable in the head nurses’ level; beyond the control or scope of the first-level managers; differences in decisions of head nurses Staff nurses may have different beliefs, views, ideas which may challenge the decision-making process; personal concerns may also a factor, thus reaching majority decision or consensus is essential in making decisions Conflict and confusion arises on situations when there were two or more options; to  choose which is better or right thing to do (i.e. charting, documentation, medication); checking institutional policies when uncertain which practice to follow Negotiation enables both sides to find a new understanding and a way forward; decision-making in approval of both parties
5. Need for collaboration	Teamwork and support	Teamwork is being able to work together in pursuit of common interest rather than his or her own; it is essential especially working in an environment composed of different people Support refers to assistance received from colleagues, especially head nurses, it drives head nurses and staff nurses to work together and achieve success Collaboration is the act of working together to achieve common goal. This is evident by the teamwork among members and support for each other.
6. Need for integration	Involvement and Interdependence	Involvement refers to engagement or participation in group transactions. Interdependence means performing tasks in mutual dependence. The need for identification refers to the need to fuse or merge one’s knowledge, skills, abilities to contribute in achieving common goal through which can be displayed through involvement and interdependence. Patient care is a round-the-clock activity, therefore, the need to integrate one’s self in discussions and decision-making to achieve safe and quality care.

Table 4: The Communication-Decision-making Matrix of Job-sharing.

Layers of experience	Questions asked	Responses	Resulting states	Thematic description
Communication	Who am I talking to?	Triad of Identities: Expertise, experience, and personality	The need for identification	The need for identification means knowing and recognizing the aspects of head nurses’ reflection of identity. In this context, participants expressed expertise, experience, and personality as determinants of identity.
		The two types of personalities
	What unifies head nurses’ differences?	Adjustment	The need for compatibility	The need for compatibility means being able to exist and perform together despite of the differences and own identities without having to change.
		Blending
	In what state does authentic communication take place?	Togetherness	The need for belongingness	The need for belongingness refers to the need of feeling a part of the team, brought about by working together and sharing common ground; a strong feeling of connection
		Relatedness
Decision-making	What should be done in times of decision conflicts?	Consultation	The need for negotiation	The need for negotiation is the need that enables both sides to find a new understanding and a way forward; decision-making in approval of both parties
		Consensus
	What strengthens our decisions?	Teamwork	The need for collaboration	The need for collaboration entails the need to act of working together to achieve common goal. This is evident by the teamwork among members and support for each other.
		Support
	Who are the actors in the decision-making?	Interdependence	The need for integration	The need for integration refers to the need to fuse or merge one’s knowledge, skills, abilities to contribute in achieving common goal through which can be displayed through involvement and interdependence.
		Involvement

Validation of correspondence was finally conducted after the thematization of data and formulation of the research model. This was achieved by going back to the participants presenting their respective interview transcripts and explaining the research model. Majority of the participants expressed that the findings of the study were congruent with their description and interpretation. To ensure credibility, member checking [37] was conducted following the steps on Table 5.

Table 5: Member Checking.

Steps	Procedures
1	Interviewer discussed interview questions with participants at the end of each interview;
2	Interviewer returned ideas back to participants to refine, rephrase, and interpret;
3	Each participant was given the chance to discuss the findings in informal post-interview session
4	Participants who were willing to provide feedback on the transcripts of their own interview as well as evaluate the research findings. A session with a sample of five participants may be done.

Results

This qualitative inquiry covers two aspects of job-sharing: communication and decision-making. Anchored by the five general questions and vignettes, participants’ responses were grouped according to each aspect. The six themes were clustered in relation to the communication and decision-making experiences.

Interestingly, the themes emerged were collectively termed as ‘needs.’ Since the aim of the study was to investigate on what the participants do and what transpires during the process, the author eidetically described and captured the phenomenon through needs as essential to the head nurses and staff nurses. The need is defined as something which is necessary and arouses an action to take place. This gives purpose and drives certain behavior in the job-sharing unit. The actual experience of the participants creates and satisfies the needs all at the same time, rather than requiring the needs (as a prerequisite) to be present to experience What is actually experienced. In other words, participants already have the experiences in a job-sharing unit, determined the innate transactions (communication and decision-making) present, and recognized the needs as lived and as part of the phenomenon.

The needs of communication include ‘the need for identification,’ ‘the need for compatibility,’ and ‘the need for belongingness.’ On the one hand, the needs for decision-making include ‘the need for negotiation,’ ‘the need for collaboration,’ and ‘the need for integration.’

The needs in communication

1. The need for identification: Who am I talking to?

The main question ‘who am I talking to?’ captured one of the most intriguing questions of people working in a job-sharing set-up. Since job-sharing requires two or more job-sharing individuals, it is important to understand to whom people are communicating with. Participants were able to relate their experiences during the communication process and were able to express their answers by describing the different aspects of identities of head nurses who shared equal roles and responsibilities. Collectively, these aspects were conveyed as ‘the triad of identities.’ Three aspects were identified as the bases for identification – experience, expertise, and personality. These guided the participants (head nurses and staff nurses alike) in communication as they work together. They were able to determine what factors might affect the communication styles and what anchored their reactions while communicating with two different head nurses.

Identity in this context refers to the qualities of a head nurse which makes her unique from her partner head nurse; this may also dictate the communication styles of each participant with a particular head nurse.

Expertise, or forte, refers to the specialized knowledge or skills of the head nurse in a specific area (i.e. medical-surgical, intensive care). Participants knew to whom they may consult or clarify matters as they render various patient care procedures. Becoming familiar with the expertise of their head nurses helped them to ask the ‘right’ questions, to facilitate satisfying answers, to relate patient cases during conversation, and to seek advice when performing patient care.

Similar to expertise, experiences also became a basis for communication. Experiences refer to the knowledge and skills gained from exposure in different events or scenarios which may be applied in the future. Head nurses were guided by their experience when they ask questions from their staff nurses about patient cases. They believed that they become more effective advisors and trainers as they provide tips to their staff nurses. They felt more confident in giving such advice if they were able to experience it in the past. This was expressed by the head nurses, as they felt at ease when their partner head nurse took over the things which they knew they encountered before.

Arguably, the most controversial determinant of identity described by the participants was the personality. Personality in this context is the collection of emotions and attitude reflected by the head nurses’ actions as perceived by co-head nurse and staff nurses. They have identified two extremes where their head nurses could be described – the strict and the lax. A participant expressed this in the following statement:

“The two of them have different personalities… I mean not really their attitude but the personality… one is lax while the other one is strict.” (R2)

Interestingly, strictness and laxness were associated with their communication experiences. Staff nurses in particular knew that a strict head nurse emphasized close conformity to policies as she gives advice, calls their attention, or reprimands them. On the one hand, a lax head nurse focuses on establishing a less-pressured environment, creating a more comfortable interaction. In line with this, participants determined other extremes of personality – these are the defender versus the not defender (opponent or other similar term was not used as it denotes negation or rivalry; participants emphasized only the potential of head nurses to defend them or not, rather than opposing them). This was specifically observed during nurse-doctor issues. Participants expressed these in the following statements:

“There’s also [a] time when for example this head nurse I know will catch you if there is a problem. But if this head nurse works with you, she’ll really point a finger at you…there are really differences, the one who will lay blame on you ‘that’s your fault’. The other one since you work with her will support you.” (R1)

“If it’s A she will defend you, if it’s B it’s up to you… you’re holding your license… (if) she’s working on the same duty with you she will defend you … but it depends if what you did is really grave then they can defend you.” (R4)

Overall, participants have expressed that the need for identification while communicating with job-sharing head nurses was crucial because it directed their behavior and reactions toward their respective head nurses. On the one hand, it does not restrict their relationships as other participants also have their own set of personalities. This study did not intend to determine each participant’s personalities and how did it affect the communication process, rather, it focused on the general description of what happened and what actions took place during their interaction as a part of job-sharing.

The need for compatibility: What unifies the differences?

The question ‘what unifies the differences?’ directs to a new understanding of their communication experiences when jobsharing head nurses possessed differences in identities. This anchoring query generated responses to determine what happened when participants encounter their respective head nurses. Majority of the participants expressed adjustment and blending as means to facilitate their interaction. These measures helped the unit to maintain harmonious relationships. They articulated that compatibility was important to focus on the complementary shades of personalities rather than seeing the contrast. Overall, this can be expressed in a formula:

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

A head nurse stated:

“So we have to adjust to the personality… on how to deal with them.” (R7)

Adjustment refers to the act of modification (approach or style) to achieve certain or desired outcome. Similar to any relationship, adjustment is one ingredient to appreciate the differences – whether knowledge or skills brought by the head nurses in the unit while working together. This was mostly evident when staff nurses asked their head nurses of particular matters regarding patient care. A staff nurse expressed that she would check on her head nurse’s mood first before asking her anything. This minimized uncertainty towards a particular head nurse’s response.

Meanwhile, blending was described as another factor in the equation. It refers to the ability to mingle with respective head nurses and co-staff nurses during conversations. Participants articulated that there were three ways to start a conversation with a particular head nurse. They described them as ‘testing the waters,’ ‘mood checking,’ and ‘right timing.’ These actions were conveyed in the following statements:

“Because I know head nurse A’s attitude… it’s like I’ll start it... by sharing stories with her… I will match with her mood.” (R6)

“I share jokes with both of them … they both get it … they are happy, but if it’s work, it’s work … if it’s just joking around, it’s ok with (head nurse) B, that’s when you see (head nurse) B.” (R4)

When adjustment and blending were combined, compatibility sets in. This is because such behaviors illuminated complementary personalities of the head nurses. Some participants expressed that communication strategies became automatic as a result of familiarizing one’s self with the head nurses’ way of interacting. The need for compatibility refers to being able to exist and perform together despite the differences and unique identities without having to change one’s identity.

3. The need for belongingness: In what state does authentic communication take place?

‘In what state does authentic communication take place?’ inquires what communication, as part of job-sharing and nursing environment, brings to the participants while they interact. The need for belongingness refers to the need of feeling a valuable part of the team, as appreciated through working together and sharing common ground. This creates a strong connection among the participants. Head nurses in particular expressed that communication per se made job-sharing favorable because it strengthened the bond between job-sharers and made the staff nurses feel that there were two ‘mothers’ willing to listen to them. Although head nurses were on full-time, 8-hour shifting basis each, the unit felt that head nurse coverage from morning to evening made all the difference.

‘Cause it is different, it seems Ma’am there is heart (in what you do), it’s like … you feel that whenever you lead them, just like you to your children.” (R7)

Relatedness, as a component of belongingness, is described as the state of sharing commonalities or similarities brought by exchanging of ideas and thoughts. Points of relatedness were evident when head nurses brought up conversation pertaining to their families, being a mother to their children, having been in the institution for almost the same length of tenure, and of course, belonging to the same age groups. A head nurse related her satisfaction in having a partner head nurse in the following statement:

“Of course Ma’am, because if you have a companion then there is someone whom you can vent your feelings too, right?” (R7)

On the one hand, another factor in the need for belongingness was the feeling of being together. Togetherness is the state of being close together which creates harmonious and strong relationship.

Relatedness and togetherness were observed as participants interact with each other. Staff nurses on the other side perceived that these components strengthened the partnership rather than drawing split communication between the head nurses. Collectively, this made each member of the unit feel part of the unit, thus the need for belongingness.

The needs in decision-making

The need for negotiation: What should be done in times of decision conflicts?

Actions in the decision-making process while working in a jobsharing permit the question ‘what should be done in times of decision conflict?’ Considering the variety of identities – from head nurse to staff nurse level and differences in opinion, ideas, and thoughts of the participants, challenges in the form of conflicts and confusion might arose. Thus, the question of what should be done in times of such situation brought attention in this study. The need for negotiation emerged as the result of participants’ responses when inquired about decision-making. This is the need that enabled both sides (head nurse and staff nurse) to find a new understanding and a way forward as they share the responsibilities of deciding together especially in patient care.

“We opt to choose what we think is better, for the betterment of the ward … I will base on what is good for the patient … for me, I choose the one that has a rationale.” (R2)

This need sought approval from both parties prior to making decisions. Since the study is anchored by a descriptive phenomenological design, determining what happens during the decision-making process, rather than the outcome, was the focus of the interview. The data collection procedure was successful in gathering participants’ experiences of what they did and what they think when talking about their decision-making, rather than knowing how each member made steps in the process. Head nurses admitted that they also engage themselves in discussion prior to decision-making.

“If she will suggest something that you think is good, you can get it …” (R5)

“We gather the idea that we think will have good effects.” (R7)

“Maybe if I know this is better, I will tell her. And then I will cite examples so she will be persuaded, so I can convince her. But if I know her decision is more reasonable, then okay.” (R11)

Evident from the participants were two means to negotiate: conferring with the supervisor and consulting institutional policies. Whenever head nurses had differences in their decisions or implementing actions, staff nurses always sought first the institutional policy. This usually satisfies the questions arising from the situations. Overall, these actions resolve challenges brought about by the decision-making in the unit.

“You know this head nurse wants this, then the other one that, so if it's like this, he or she will end up following the policy abided by the nursing training office... so it will go back to what the policy really is.” (R1)

“But in case we are there, we talk it over because usually we have monthly meetings, so together with our supervisor, we are able to talk about everything... usually voting among us... 'who is in favor?' Like that, so if there are majorities, then they are followed.” (R12)

The need for collaboration: What strengthens our decisions?

The potential of the participants to act on and for the decisions is referred in this study as the need for collaboration. Consequently, it answers another decision-making question, ‘what strengthens our decisions?’ The need for collaboration entails the need to act of working together to achieve common goal while making safe and patient-centered decisions. This is evident by the teamwork among members and support given for each other.

Teamwork in the context of the study refers to uniting the actions of different individuals while putting common goals in higher priority than his or her own. Support, on the one hand, is equally the assistance offered and received by each member as he or she went through the decision-making and even after choosing among the options.

“With head nurse A, you will be pushed to do what is right, with head nurse B is just okay, you won’t be afraid of your wrong decision because she is there to support (you)” (R6)

When both were paired, teamwork and support were likely to strengthen the decision-making activities of nurses. Interestingly, head nurses felt the same need within their level because roles and responsibilities called for collaborative actions displayed through team playing and supporting each other.

The need for integration: Who are the actors in decision-making?

The need for integration completes the list of needs described in the decision-making and communication of the participants. This refers to the need to fuse or merge one’s knowledge, skills, and abilities to contribute in achieving common goals. This can be displayed through involvement and interdependence. Involvement and interdependence answer the question, ‘who are the actors in decision-making?’ As defined, involvement is the engagement or participation in the group tasks, in this context, the decision-making. This was complemented by interdependence wherein participants felt that there was a mutual dependence when making decisions, especially the critical ones. This theme explains who participates in the decision-making process of the unit.

“Both of you are responsible for the unit … Both of you are accountable… both of you, both of you are responsible, so if in decision-making … You have equal responsibilities when it comes to your patients, everything is on both of you.” (R1)

Importantly, head nurses expressed that they were both involved and displayed interdependence when they make decisions for the unit. Decisions were associated with staff nurse disciplinary actions, staffing and scheduling, delegation of tasks, employing pair-up (buddy system) among the staff nurses, and other managerial concerns. All head nurses stated that they were all have the same privileges of being heard and making the final say when they discuss important issues in the unit.

Collectively, the foregoing themes are presented using a data display called matrix. A matrix is simply described as an intersection of columns and rows [38]. It is a type of data display, different from a network, which is utilized mainly to systematically arrange and present the research questions and answers at hand. Because it organizes all the information coherently and concisely, it facilitates the drawing of conclusions by merely looking at it or reading through it. In the context of this study, the data display is called ‘The Communication-Decision-making Matrix of Jobsharing.’

Discussion

The overall results of the study formulated the six needs of jobsharing unit as illustrated by a matrix called The Communication- Decision-making Matrix of Job-sharing. The need in the context of this study refers to something which is necessary and arouses an action to take place. This gives purpose and drives certain behavior in the job-sharing unit. It suggests that the needs identified are all interrelated and interdependent, however, do not necessarily transpire in sequence, nor it do not imply that a certain need must be met first to achieve other needs. Majority of the participants expressed satisfaction towards the set-up and preferred this when working in big areas, such as those which have high patient census and high number of health care staff employed. Staff nurses also expressed that they look forward in working with a partner in the future if they would be promoted as a head nurse.

Challenges and demands brought by the changes in the nursing management have motivated this qualitative inquiry. In a developing country like the Philippines, there is only a little understanding on decision-making and communication among nurses. Decision-making and communication experiences may just be recalled and cannot be observed in actual, hence, the use of descriptive phenomenology design. Since job-sharing is not widely employed in the country especially in the health sector, it is necessary to conduct investigation such as this. The following entails the discussion of the themes emerged in this qualitative investigation.

The needs in communication

Job-sharing entails higher frequency of communication since there are two head nurses involved in the process. The head nurses are believed to be people having more experiences and possessing expertise in the field resulting from their tenure and exposure in the practice. Dubourg, Ahmling, and Bujas asserted that nurses who become experienced and knowledgeable with advanced clinical, management, leadership, and human resource skills reach the point in their career where they become suitable candidates for nurse manager roles [15]. Their distinct expertise and experiences helped them become adaptive and quick in analyzing the situation. Benner, as cited by Edwards argued that growth in nursing expertise is characterized by movement from reliance on rules to the use of clinical experience [39].

Being an expert means being able to possess a specialized body of knowledge, having extensive experience in that field of practice, having highly developed levels of pattern recognition, and being acknowledged by others [39,40]. As the participants worked together, it was clear that the head nurses’ expertise and experiences influenced how they communicate with each other.

The differences of head nurses in their identities posed impact to their communication experiences since they made valuable input and contribution to the knowledge and skills of the staff nurses. At the same time, staff nurses were familiarizing themselves with each head nurse’s identities.

Through communication, staff nurses were able to identify and ‘label’ their head nurses in terms of their personalities. It is a commonplace in a job-sharing set-up that the job-sharers' actions reflect their identities. The strongest descriptions emerged were either ‘being strict’ or ‘being lax.’ Meanwhile, head nurses were not exempted from seeing each other’s differences. They felt that their personality distinguished them from their partner head nurse.

Participants expressed that comparison between head nurses was inevitable. They recognized this because staff nurses and head nurses get to work with each other in a shifting basis. Particular reason for comparison was staff nurses felt ‘hesitation versus comfort’ when communicating and ‘pressure versus ease’ atmosphere while working with specific head nurses. Staff nurses in this type of set-up might look for something of significance or in favor with them while working. Dubourg et al. have argued that staff nurses valued the ‘empathic’ approach of one of the job-sharing managers when communicating [15].

The need for identification was crucial to each member of the unit because it helped them establish the working relationship and made dealing with the head nurses’ differences much easier and bearable.

The need for compatibility unifies the overall differences in identities. This need arouses adjustment and blending to take in. This combined action makes every participant work actively on their communication strategies. Adjustment and blending were learned overtime, as a result of interacting with respective head nurses in a shifting basis. Participants expressed that rather than focusing on the differences as detrimental to their communication, they took this as an asset instead. It means that they value the combination of personalities of head nurses because they felt variety and well-roundedness. This paved the way to appreciating the complementary attributes instead of comparing and contrasting. Further, when staff nurses and head nurses learned how to adjust and blend with each other, compatibility sets in. This resulted to diminished occurrence of misunderstandings and communication splits.

In a study by Rogers and Finks, they found that when a partnership is consisted of two committed and compatible employees, who have unique individual strengths, benefited the employer [6]. This is supported by the present study since head nurses expressed that they felt confident to be rotated in different wards and assigned challenging tasks because of the experience they gained from job-sharing. In separate studies by Branine and Spencer, as cited by Woodhouse, Finn, and Johnson- De Wit, they asserted that compatibility was the keystone for the job-sharers experiencing the job-sharing [33]. Dubourg et al. on the one hand, argued that a shared position can be successful when administered by two skilled managers who bring different personalities with different views and different ideas, creating fresh, stimulating solutions that may reach beyond the potential of the single individual [15].

Woodhouse et al. argued that sharing of a role may not always be effective for situations that personalities may not get along and that compatibility is a challenge [33]. It should be noted that when two persons operating within the role were not compatible or did not meet halfway, there would be a risk of communication breakdown.

Communicating with job sharers on a regular basis, resolving conflict, and setting clear goals and responsibilities are necessary in this type of working arrangement [6]. Moreover, this present study affirms the findings of Dubourg et al. wherein the jobsharing nurse managers must be able to complement each other to maintain harmonious relationships among head nurses and staff nurses [15].

Apart from the need for identification and compatibility, participants also sought the need for belongingness; the third need arising from the communication experiences of the participants. This need refers to the necessity of feeling belong as they exchange feelings, thoughts, and ideas with the person they talk to. Head nurses expressed that communication with their partner head nurse was as important as interacting with their staff nurses. This need for belongingness encouraged the staff nurses to feel as part of the family, rather than feeling left out from the partnership of their head nurses.

Head nurses from two separate units were all females, married, and working mothers. These similarities established a sense of belongingness with their partner head nurses and at the same time helped them to relate their feelings and emotions. It also strengthened their working relationship as they felt the connection between them.

Head nurses expressed that being a woman and a mother helped them to deal with their staff nurses, considering that they also had their own differences. It was conveyed that there was more personal touch; enabling them to treat their staff nurses like their children. They also valued the skill for listening and providing feedback. It was expressed in the interviews that incorporating motherly behavior was a tool to establish trust between head nurses and staff nurses. Sun, Lim, Jiang, Peng, and Chen cited in their study that females have focus on intimacy and solidarity in the communication process which tends to strive for harmony and rapport, and give positive evaluation to others’ opinion. This is very true with the set-up of the participants. Women are known to be relationship-oriented [41,42].

The needs in decision-making

No team can be exempted from challenges. Conflicts for the participants were inevitable due to their differences in opinion and ideas as they make decisions. This is usually evident during their involvement in patient-care and personal concerns. It was argued that most organizations are susceptible to conflict and the clinical setting is no exception [43-45]. Involvement of two head nurses and the staff nurses in any or all aspects of their working set-up had a potential for misunderstanding and confusion.

The outcomes of conflict, especially in a role shared by two employees, affect the members as well as organizations, and management of interpersonal conflict determines whether the outcomes will be positive or negative [46-48]. Some source of conflict arose from nurse-doctor relationship, which was not substantiated in this study. However, emphasis on the actions made for these conflicts was entertained. As highlighted in Allen’s work, potential areas of conflict were managed or negotiated, predominantly by the nursing staff [49]. Hence, it was necessary for the participants to deal with the challenges promptly and effectively. Negotiating differences was the key solution for these challenges. There were three actions that the participants described as they negotiate their differences. These were conferring with their supervisor, consulting and conforming to the institutional policies, and reaching the consensus.

The need for collaboration captures the general answer to ‘what strengthens’ the decision-making process in a job-sharing unit. As explicated earlier in this study, decision-making is a multifactorial process which may influence the outcome of patient care. Similar to job-sharing set-up, the input of each head nurse is equally important for all staff nurses because both head nurses hold the same amount of accountabilities and responsibilities.

Job-sharing accounts two individuals in the same level to collaborate as they were given the equal roles and responsibilities. Likewise, on the part of the head nurses, they made sure that both of them have to demonstrate support for each other’s decisions. An example of which is when they were making decisions for disciplinary measures or giving considerations for staff nurses needing schedule requests (i.e. continuing education). They understood that their decisions – whether big or small, impact the whole unit. Participants expressed that patient-care decisions were considered the most crucial among the decisions. These influence the relationship among healthcare members (doctors, nurses, patients, and other health-allied professionals). This finding was supported by Ahmed and Safadi who posited that the responsibility of making decisions influences patients and employees as well as their own actions [22].

Other scenarios wherein the need for collaboration was evident were through sharing of ideas and opinion and seeking advice and help when they make decisions. Usually, a staff nurse consults his or her head nurse prior to performing procedures. Consequently, the head nurse responds by showing support and assistance to the staff nurse.

Job-sharing as employed in the nursing unit necessitates greater effort for collaboration. This is mostly true because there were two head nurses to whom staff nurses interact with prior to making decisions. Comparably, participants learned the essence of teamwork as they contribute to the knowledge and skills needed by the unit in performing tasks and procedure. This should emphasize that head nurses should foster a positive and safe environment that allows for open and respectful communication which results in trust [50].

Nurse managers who work in a job-sharing set-up emphasized the importance of working in ‘transparent determination’ or knowing what is going on [20]. This argument support the responses of the participants wherein they expressed that decisions, whether made independently or interdependently, should be known and informed. Endorsement, as one of the nursing tasks, displays that collaboration among head nurses and staff nurses is important for the whole team. It cannot be that a head nurse is completely unaware of what is going, what decisions have been made, and who were affected by the decisions.

Job-sharing, as the term implies, involves not just one person but two or more. In this context, head nurses were sharing managerial roles and responsibilities. To concretize this in decision-making aspect, staff nurses were expected to involve two head nurses as they make decisions. As an example, a decision made during her shift has been derived with the help of the head nurse on duty. Consequently, this would be endorsed to the incoming head nurses to make sure that actions were monitored. This even facilitated head nurse-doctor interaction because there were times that the head nurses’ opinion is solicited.

Demands of the nursing profession require integration among all levels. This is to encourage taking part into the practices and culture of the unit. This present study is not confined in a usual head nurse-staff nurse relationship. This involves two head nurses, who make decisions within their level, and staff nurses who share decisions with the head nurses as well. It emphasized that no one can be bypassed in the decision-making.

Sharing decisions between head nurses also necessitates integration. This is usually observed when head nurses consciously make effort to involve themselves in the decisionmaking process. At the same time, it is implied to them that one cannot make decisions right away especially when it would affect both of them, thus, the interdependence.

The need for integration sets the foundation for and maintains the helping and supportive relationship among the members. It also steers members of the unit to become more participatory, hence, effective and efficient in providing health care to the patients. Woodhouse et al. found that job-sharing provided a strong sense of support for both incumbents of the position [33]. Majority of the participants preferred working in this type of setup because they felt a sense of accomplishment and satisfaction toward their work. Staff nurses appreciated how having two head nurses influence their profession and maturity.

Summarily, staff nurses expressed that all needs described widened their horizons, developed their decision-making skills and critical thinking, and enhanced their communication strategies. Head nurses, on the one hand, conveyed that shared decisions and open and transparent communication increased their knowledge and improve their leadership skills. The concept needs is the overall description of the decision-making and communication experiences of head nurses and staff nurses working in a managerial job-sharing set-up.

The Communication-Decision-making Matrix of Job-sharing is used to represent the themes emerging from the study. The needs identified are the eidetic description of the phenomenon. It answers the central question “how do head nurses and staff nurses describe their decision-making and communication when job-sharing is employed at the managerial level?” The needs are the essence of the experience among head nurses and staff nurses [51-71].

Conclusions and Recommendations

Head nurses and staff nurses learned throughout their experiences that there were needs arising from their communication and decision-making experiences while working at the managerial job-sharing set-up. These needs facilitated their daily transactions specifically in decision-making and communication. The participants have understood essential ingredients to acquire and adapt for them to become effective member of their unit. The themes identified from the description of their experiences entail the needs of job-sharing.

The Communication-Decision-making Matrix of Job-sharing represents the needs coming from the job-sharing set-up. Each need is met when the factors are present. Communication and decision-making are the two layers of experience in this qualitative inquiry. The column showing the ‘questions asked’ refers to the capturing questions of the experiences. The responses were the factors needed to meet the needs. The ‘resulting states’ are the descriptions of the phenomenon. The ‘thematic descriptions’ explain the meaning of the themes. The matrix shows that the needs do not necessarily transpire in chronological order to achieve certain goal or objective. No need is described to be lower or higher over the others.

It is evident from the study that head nurses and staff nurses viewed job-sharing as a management strategy which integrated their knowledge and skills in making decisions, promoted open and transparent communication, and maintained a harmonious working relationship. The needs that were identified to transpire in their day-to-day routines steered the unit to perform effectively upholding a supportive environment. It also negated the traditional connotation of conflicts as detrimental or destructive. It was recognized as a challenge which must be addressed by the participants as a team.

This is one of the few studies to describe the views of head nurses and staff nurses on the two most important processes in nursing – decision-making and communication. The nature of this qualitative investigation led to ensure credibility following the framework of Guba & Lincoln as cited by Zhang and Wildemuth [37]. Member checking was done by discussing the guide questions with participants prior to interview proper and feeding the ideas back to participants to refine, rephrase, and interpret.

A semi-structured interview schedule was carefully constructed through support of the research supervisor to lessen the potential for any bias. The study, as might be expected for a study of this size, had a number of limitations. Firstly, because of the chosen design, actual experience in decision-making and communication were not directly observed. The time it took for the study to be accomplished and frequency of the interviews also added up to the limitations. Lastly, given the number of the participants, future studies may increase to strengthen generalizability.

Overall, the participants expressed the needs to be met in decision-making and communication aspects in job-sharing. In addition, they argued that job-sharing at the managerial level is satisfactory in the type of the work they have as evidenced by the positive remarks and wanting to retain the set-up in the unit. Head nurses did not convey any form of competition or rivalry in the position as they hold independence in their accountabilities and responsibilities. Meanwhile, staff nurses favored the presence of two head nurses because they felt confident that there is always someone to assist and support them in times of needs within their shift. Thus, the usual perception of only one person being able to provide the best leadership for the unit was disproved by this study.

Staff nurses expressed their appreciation and satisfaction in having two head nurses. It was similar to having two parents whom they knew they could rely on. Head nurses also supported this premise as they articulated the ease and comfort of having a partner while they do stressful and challenging roles and responsibilities.

The author wishes to recommend job-sharing as both a retention and recruitment strategy for nurses in the country. Since our country faces high unemployment and high migration of skilled nurses, job-sharing may be considered as one of the solutions as it offers the convenience of work-life balance; meeting the demands of family and children at home, while growing in the career both personally and professionally.

Interestingly, this qualitative investigation confirms that there is so much to understand in decision-making and communication among nurses. In addition, it may be recommended to hospital administrators to adapt job-sharing arrangement to retain our skilled professional nurses and to provide opportunity for the beginning nurse practitioners by employing them in a job-sharing set-up, may be in a mixture of job-sharing and job-splitting.

Moreover, it is known that some nurses at the middle-age wish to continue higher education while being hands-on parents to their children and caregivers to aging parents or relatives. With this entire dilemma, nurses are likely to choose one over the other. However, job-sharing minimizes the stress of the situation since it caters and advocates flexible working arrangement, thus, worklife balance. Nurses who seek a better balance between family life and career without having to be employed outside the country are most suitable in job-sharing set-up. Job-sharing offers a more flexible way of addressing the needs of usually a beginning family and growing career. Despite the stress, challenges, and demands of a managerial position, head nurses may be able to find a way to integrate their life and work. Further, job-sharing has a high potential to become effective for nurses who are willing to work together and open for consultation and discussions with their partners.

Despite of few literatures suggesting higher cost for job-sharing, this study supports others which argued otherwise. This is because job-sharing retains highly skilled and specialized head nurses who can contribute to the professional development of beginning nurses through mentoring and training. Recruitment, orientation, and training for newly hired (or external) head nurses are proved to be more costly compared to retaining head nurses. The needs identified from communication and decisionmaking aspects may serve as a basis for job-sharing procedures and policies.

Reasons for job-sharing are diverse. These may be congruent depending on the needs of a nurse. Since this study investigated on the job-sharing as employed at the managerial level, career development and enhancement are seen as few of the major advantages. Continuing further education or enjoying wide array of knowledge and skills brought in by partnering head nurses is considered as a reason for engaging in job-sharing.

On the one hand, it serves as a helpful tool in training and mentoring. A newly promoted, less experienced head nurse may learn managerial skills from her mature, more experienced partner. Administrators may be able to cut down their budget in special trainings intended for newly hires and allot it to other areas such as incentives for performances, resource and materials needed by the unit, or research grants for the hospital employees.

Job-sharing has been agreed to minimize burn-out especially on the part of the head nurses as it ease the burden of being responsible for the unit all the time. Job-sharers are confident that their partner head nurse is visible in the unit and provide coverage for each staff nurse while they are away from work. In addition, it reduces the number of sick days as job-sharers are not exhausted despite the bulk of their duties. Continuity of supervision without passing the buck is also an observed advantage of job-sharing among head nurses.

Prior to employing and engaging job-sharing in the unit, partner selection must be examined carefully – considering all the needs presented in a job-sharing set-up. Determining demographic profile, personality assessment, expertise and experience evaluation are the keys to make a suitable and effective partnership. Although knowing the partner personally is argued to be not so important, it may be beneficial in some ways.

Despite the advantages that job-sharing offers to the majority, careful and keen examination prior to implementation must be employed. Compatibility checking between job-sharers may be one of the most important aspects to be considered before setting up employees in job-sharing. A pilot testing may be helpful for assessment of the strengths and weaknesses it may have. Compatibility in communication styles is one of the keys to successful job-sharing. It promotes exchange of ideas and consultation related to the programs being implemented in the unit.

Job-sharing nurses are becoming more appreciated as they exert effort and contribution for meeting the goals and objectives of the unit. Their partnership may be seen as a dedication to their work and commitment with their colleagues. Open communication is likely to be observed as job-sharing requires interaction between job-sharers and other members of the team.

Indeed, job-sharing nurses and hospital administrators must also watch out for the challenges and disadvantages job-sharing may brought to the organization. Incompatibility is one of the problems that may be felt during the early stage of job-sharing. Since it usually pairs up employees ready for the position, key assessment areas such as compatibility checking is not greatly observed. Compatibility is seen overtime as two or more individuals interact and relate with each other as they work together.

Dividing tasks such as staffing, deliverables, and inventory may be problematic if one feels overworked or underworked. Job-sharing pairs should be clear with each other how they assign tasks. One of the simple actions made by job-sharers is the alternating assignment of tasks and duties (i.e. monthly, quarterly). In addition, job-sharers must be aware of the potential for role possessiveness as they become experienced and familiar with the culture of the unit.

Since there were no evidences in the local literatures that a ‘third’ head nurse might be employed for night shifts, it is recommended for researchers to venture their inquiry in this situation. For nurse managers and administrators, developing a model which involves job-sharing may be advisable.

Arguably, the feasibility and success of job-sharing lies on the meeting the needs discussed earlier in this study. The needs identified within the communication and decision-making aspects arouse the action directed toward achieving common goals and objectives of the unit and the organization.

7905

References

1. Zastocki D, Holly C (2010) Retaining nurse managers. American Nurse Today, United States of America
2. Hayes LJ, O'Brien-Pallas L, Duffield C, Shamian J, Buchan J, et al. (2012) Nurse turnover: a literature review - an update.  Int J Nurs Stud 49: 887-905.
3. Harris R1, Bennett J, Davey B, Ross F (2010) Flexible working and the contribution of nurses in mid-life to the workforce: a qualitative study.  Int J Nurs Stud 47: 418-426.
4. Eick JC (2002). Job sharing their first year: a narrative of two partnered teachers’ induction into middle school science teaching. Teach TeachEduc 18: 887-904
5. Kocolowski M (2010) Shared leadership: Is it time for a change? ELJ 3: 22-32
6. Rogers KC, Finks SW (2009) Job sharing for women pharmacists in academia.  Am J Pharm Educ 73: 135.
7. Gholipour A, Bod M, Zehtabi M, Piranneiad A,Kozekanan S (2010) The feasibility of job sharing as a mechanism to balance work and life of female entrepreneurs. Int Bus Res 3: 133-140
8. Fallis K, Altimier K (2006) Shared leadership: Leading from the bottom up. Newborn Infant Nurs Rev 6: 3-6
9. Parsons ML, Stonestreet J (2003) Factors that contribute to nurse manager retention.  Nurs Econ 21: 120-126, 119.
10. Kath LM, Stichler JF, Ehrhart MG, Sievers A (2013) Predictors of nurse manager stress: a dominance analysis of potential work environment stressors.  Int J Nurs Stud 50: 1474-1480.
11. Allan A, Daniels L (1999) Part-Time Workers. Chartered Institute of Personnel. United Kingdom
12. Balls P (2009) Phenomenology in nursing research: methodology, interviewing and transcribing.  Nurs Times 105: 30-33.
13. Rosengren K, Bondas T, Nordholm L, Nordström G (2010) Nurses' views of shared leadership in ICU: a case study.  Intensive Crit Care Nurs 26: 226-233.
14. Cziraki K, McKey C, Peachey G, Baxter P, Flaherty B (2014) Factors that facilitate registered nurses in their first-line nurse manager role.  J NursManag 22: 1005-1014.
15. Dubourg L, Ahmling JA, Bujas L (2006) Can job sharing work for nurse managers?  Aust Health Rev 30: 17-24.
16. Zuzelo P, McGoldrick TB, Seminara P, Karbach H (2006) Shared governance and EBP: a logical partnership?  Nurs Manage 37: 45-50.
17. Cathmoir D, Mullooly C, Brewer D, Miller (1999) Job sharing senior clinical roles: Heaven or hell!.Eur J Cancer 35: 46-47
18. Bamford-Wade A, Spence D (2012) Shared governance: a vehicle for engagement and change.  Nurse Educ Today 32: 191-194.
19. Ochs S (2001) Succeeding with job sharing in elementary classrooms: A Resource. Dr. Stirling McDowell Foundation for Research into Teaching Inc Canada
20. Rosengren K, Bondas T (2010) Supporting "two-getherness": assumption for nurse managers working in a shared leadership model.  Intensive Crit Care Nurs 26: 288-295.
21. Bamford-Wade A, Moss C (2010) Transformational leadership and shared governance: an action study.  J NursManag 18: 815-821.
22. Ahmed M, Safadi E (2013) Decisional involvement among nurses: Governmental versus private hospitals. Health Sci J 7: 18 -27
23. Hoffman K, Aitken L, Duffield C (2009)A comparison of novice and expert nurses’ cue collection during clinical decision-making: Verbal protocol analysis. Int J Nurs Stud 46: 1335-1344
24. Nielsen K, Yarker J, Randall R,Munir F (2009)The mediating effects of team and self-efficacy on the relationship between transformational leadership, and job satisfaction and psychological well-being in healthcare professionals: A cross-sectional questionnaire survey. Int J Nurs Stud 46: 1236-1244
25. New N (2009) Shared governance: Virginia’s empowering nursing leaders speak. Nurse Leader 7: 44-46
26. Gunnarsson BM, WarrénStomberg M (2009) Factors influencing decision making among ambulance nurses in emergency care situations.  IntEmergNurs 17: 83-89.
27. Watkins M (1998) Decision-making phenomena described by expert nurses working in urban community health settings. J Prof Nurs14: 22-33
28. Thompson C, Aitken L, Doran D, Dowding D (2013) An agenda for clinical decision making and judgement in nursing research and education.  Int J Nurs Stud 50: 1720-1726.
29. Harding T, Sque M (2010) Do leadership skills impact clinical decisions made by ward managers? Nurse Leader 8: 42-45
30. Barden AM, Griffin MT, Donahue M, Fitzpatrick JJ (2011) Shared governance and empowerment in registered nurses working in a hospital setting.  NursAdm Q 35: 212-218.
31. Muethel M, Hoegl M (2010) Cultural and societal influences on shared leadership in globally dispersed teams. Int J Manage 16: 234-246
32. Creedle C, Walton A (2012) A better balance: Sharing the nurse manager role. Nurse Leader 10: 30-32
33. Woodhouse G, Finn T, Johnson-De Wit K (2013)To investigate the concerns and benefits of job sharing a community based clinical nurse consultant role. Aust J AdvNurs 30: 33-40
34. Acorn S, Williams J, Dempster L, Provost S, McEwan C (1997) Job sharing at the managerial level.  Nurs Manage 28: 46-48.
35. Berg B (1995) Qualitative research methods for the social sciences. Michigan: Allyn& Bacon Inc, United States of America
36. Bjørk IT, Hamilton GA (2011) Clinical decision making of nurses working in hospital settings.  Nurs Res Pract 2011: 524918.
37. Zhang Y, Wildemuth BM (2009) Qualitative analysis of content. Applications of Social Research Methods to Questions in Information and Library Science, 308-319, Westport, CT: Libraries Unlimited, USA
38. Brunetto Y, Farr-Wharton R, Shacklock K (2012) Communication, training, well-being, and commitment across nurse generations.  Nurs Outlook 60: 7-15.
39. Edwards B (1998) A & E nurses' constructs on the nature of nursing expertise: a repertory grid technique.  AccidEmergNurs 6: 18-23.
40. Brahnam S, Hignite M, Margavio T, Barrier T, Chin J (2004) Are women in IS better at managing conflict? AMCIS, United States
41. Gefen D, Straub D (1997) Gender difference in the perception and use of E-mail: An extension to the technology acceptance model. MIS Quarterly 21: 389-400
42. Creswell JW (2006) Five Qualitative Approaches to Inquiry. AHPA Chapter 4: 53 - 84
43. Chan JCY, Sit ENM, Lau WM (2013) Conflict management styles, emotional intelligence and implicit theories of personality of nursing students: A cross-sectional study. Nurse Education Today 34: 934-939
44. Duffield CM, Roche MA, Blay N, Stasa H (2011) Nursing unit managers, staff retention and the work environment.  J ClinNurs 20: 23-33.
45. Fotheringham D (2013) Confident to seek help: the development of skill and judgement in nurse practitioners. A mixed methods study.  Nurse Educ Today 33: 701-708.
46. Gillespie M (2010) Using the Situated Clinical Decision-Making framework to guide analysis of nurses' clinical decision-making.  Nurse EducPract 10: 333-340.
47. Groenewald T (2004)A phenomenological research design illustrated. Int J Qual Methods 3: 1-25
48. Coombs M (2003) Power and conflict in intensive care clinical decision making.  Intensive Crit Care Nurs 19: 125-135.
49. Hardcastle VG (2004) Thinking about consciousness. AnalytPhilos 45: 223-227
50. Hoeger P, Wilson J, Evans J (2009) Cultivating nurse leaders from the bedside to the boardroom. Nurse Leader 7: 41-45
51. Johnstone PL (2003) Nurse manager turnover in New South Wales during the 1990s.  Collegian 10: 8-16.
52. Manias E, Street A (2001) The interplay of knowledge and decision making between nurses and doctors in critical care.  Int J Nurs Stud 38: 129-140.
53. McInally W, Masters H, Key S (2012) The impact of paediatric oncology education on clinical practice -- a phenomenological study.  Eur J OncolNurs 16: 498-504.
54. McNamara MS (2005) Knowing and doing phenomenology: the implications of the critique of 'nursing phenomenology' for a phenomenological inquiry: a discussion paper.  Int J Nurs Stud 42: 695-704.
55. Newman KP (2011) Transforming organizational culture through nursing shared governance.  NursClin North Am 46: 45-58.
56. O'May F, Buchan J (1999) Shared governance: a literature review.  Int J Nurs Stud 36: 281-300.
57. Peterson LW, Halsey J, Albrecht TL, McGough K (1995) Communicating with staff nurses: support or hostility?  Nurs Manage 26: 36-38.
58. Porter-O'Grady T (2001) Is shared governance still relevant?  J NursAdm 31: 468-473.
59. Rosenblatt CL, Davis MS (2009) Effective communication techniques for nurse managers.  Nurs Manage 40: 52-54.
60. Schmalenberg C, Kramer M (2009) Nurse manager support: how do staff nurses define it?  Crit Care Nurse 29: 61-69.
61. Scott L, Caress AL (2005) Shared governance and shared leadership: meeting the challenges of implementation.  J NursManag 13: 4-12.
62. Shosha G (2012) Employment of Colaizzi’s strategy in descriptive phenomenology: A reflection of a researcher. EurSci J 8: 31-43
63. Srsic-Stoehr K, Rogers L (2004) Success skills for the nurse manager: Cultural debut and sustainment, Nurse Leader 2: 36-41
64. Corazzini KN, Anderson RA1, Rapp CG2, Mueller C3, McConnell ES1, et al. (2010) Delegation in Long-term Care: Scope of practice or job description?  Online J Issues Nurs 15.
65. Wojnar DM, Swanson KM (2007) Phenomenology: an exploration.  J Holist Nurs 25: 172-180.