Empowering nurse leaders: leveraging financial management practices to foster sustainable healthcare – a mixed-methods study

This study utilized a convergent parallel mixed-methods approach, where quantitative and qualitative data were collected simultaneously and analyzed separately that used to assess nurse leaders’ perceptions regarding their financial management practices and their relationship to patient care quality and outcomes. The design combined quantitative data collection through structured questionnaires and qualitative data collection via open-ended responses to provide a comprehensive understanding of the topic. The study involved 87 nurse leaders from various private hospitals across Egypt. The selection process utilized a multistage sampling approach. Initially, hospitals were randomly chosen from four major regions: Northern Egypt (10 hospitals), Upper Egypt (15 hospitals), Eastern Egypt (10 hospitals), and Western Egypt (7 hospitals). An additional 45 hospitals were selected from Cairo and the Delta region. Nurse leaders participating in the study were required to have a minimum of five years of nursing experience and hold at least a bachelor’s degree in nursing or higher. In the second stage, nurse leaders were chosen through a non-probability convenience sampling method, targeting individuals in leadership positions such as Regional Nurse Managers (10), Chief Nursing Officers (6), and Nurse Managers (60). The sample size was determined using Cochran’s formula (Cochran, 1977) [18].

The formula used in equation seems to follow the standard form of Cochran’s formula:

where:

The total sample size was 87 participants.

The study’s inclusion criteria ensured that participants possessed the necessary qualifications and experience to offer meaningful insights into financial management practices. Eligible nurse leaders were required to hold a bachelor’s degree in nursing or higher, such as a master’s or doctoral degree. Furthermore, participants needed at least five years of nursing experience, including a minimum of two years in a leadership or managerial position, such as Regional Nurse Manager, Chief Nursing Officer, or Nurse Manager.

The fieldwork for this study took place over a three-month period, from April to June 2024, in selected private hospitals across Egypt. Hospitals were selected through a simple random sampling method from four primary regions: Northern, Upper, Eastern, and Western Egypt. Eligible nurse leaders were identified using a non-probability convenience sampling approach, targeting individuals in leadership positions such as Regional Nurse Managers, Chief Nursing Officers, and Nurse Managers. Prior to data collection, ethical approval was secured from the Ethical Committee of the Faculty of Nursing at Helwan University, along with necessary permissions from hospital administrations. Participants underwent careful screening to ensure they met the inclusion criteria, including required educational qualifications and leadership experience.

Data collection involved administering The Nurse Leaders’ Financial Management Practices Assessment (NLFMP), a structured questionnaire designed to assess financial management practices across five dimensions: Budgeting, Resource Allocation, Cost-Effectiveness, Decision-Making, and Impact on Patient Care. The questionnaire included both closed-ended items rated on a 5-point Likert scale and open-ended questions for qualitative insights. Researchers distributed the questionnaires in person and provided participants with a comfortable, private environment to complete the survey during their work shifts, ensuring minimal disruption to their responsibilities. Each questionnaire took approximately 10–20 min to complete, and informed consent was obtained from all participants after explaining the study’s purpose, voluntary nature, and confidentiality protocols. Following data collection, all completed questionnaires were securely collected and anonymized to maintain participant confidentiality. Quantitative data were analyzed using IBM SPSS Statistics (version 26.0), while open-ended responses were transcribed verbatim and subjected to thematic analysis to identify recurring themes and gain deeper insights. This methodical approach to fieldwork ensured a comprehensive understanding of nurse leaders’ financial management practices while respecting the time and commitments of the participants.

Qualitative data were collected from a nurse leaders using semi-structured interviews and open-ended survey responses to gain deeper insights into their financial management experiences. Participants were selected through purposive sampling to ensure diversity in age, experience, and job roles (Chief Nursing Officers, Nurse Managers, Regional Nurse Managers). Interviews were conducted face-to-face or via Zoom, lasting 30–45 min, and were audio-recorded with consent. Open-ended questions explored financial decision-making challenges, budgeting constraints, and resource allocation strategies, encouraging participants to share real-life experiences. Additionally, open-ended survey responses provided further qualitative input, allowing participants to elaborate on key financial management practices. Thematic analysis was used to identify recurring patterns, such as budget limitations, staffing shortages, and the impact of financial decisions on patient care, which were then integrated with quantitative findings for a comprehensive understanding of nurse leaders’ financial competencies.

A coding framework was developed to identify recurring themes, such as budget constraints, staffing shortages, and financial decision-making influence. Thematic findings were then compared with quantitative results to integrate insights and highlight consistencies or discrepancies.

The internal consistency of the Nurse Leaders’ Financial Management Practices Assessment (NLFMP) tool was assessed using Cronbach’s alpha to ensure its reliability within the study sample. After refining the items, the overall Cronbach’s alpha was recalculated and found to be 0.82, indicating strong internal consistency. The reliability analysis for each subscale showed acceptable to high consistency, with Budgeting Practices having the highest reliability (α = 0.85), followed by Cost-Effectiveness (α = 0.81), Patient Impact (α = 0.80), Resource Allocation (α = 0.79), and Decision-Making Influence (α = 0.76). These results confirm that the NLFMP tool is a reliable measure for assessing financial management practices among nurse leaders in this study.

Bartlett’s test of sphericity was performed to determine the adequacy of the data for factor analysis, yielding a significant result (p < 0.001). Additionally, the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was calculated and surpassed the minimum acceptable value of 0.7, confirming the suitability of the dataset for factor analysis, as mentioned in Table 1.

A triangulation approach was used to integrate quantitative and qualitative findings, ensuring a comprehensive understanding of nurse leaders’ financial management practices. Thematic analysis of qualitative data was compared with quantitative results to validate, expand, and explain key trends across five domains: budgeting practices, resource allocation, cost-effectiveness, decision-making influence, and impact on patient care.

Quantitative results indicated that budgeting practices had a moderate mean score (3.90 ± 0.50), suggesting variability in budgeting proficiency. Qualitative findings expanded on this by revealing that nurse leaders faced challenges due to limited financial training and unclear budget policies, affecting their ability to allocate funds effectively. Similarly, resource allocation scored slightly lower (3.85 ± 0.55), with qualitative insights highlighting frustration over financial constraints and limited decision-making authority, which restricted nurse leaders’ ability to allocate resources efficiently.

The cost-effectiveness domain received a relatively high rating (4.05 ± 0.45), which qualitative findings validated by showing that nurse leaders employed strategic cost-saving measures such as optimizing staff shifts and negotiating supplier agreements. However, some participants expressed concerns that balancing cost-efficiency with maintaining care quality was a constant challenge. Decision-making influence had the highest mean score (4.10 ± 0.48), with qualitative responses confirming that senior nurse leaders felt empowered in financial decisions, while those in lower positions had limited involvement in budgetary planning.

The final domain, impact on patient care and outcomes, was strongly rated (3.95 ± 0.47), with qualitative findings reinforcing that financial constraints, such as staff shortages and limited medical supplies, directly affected patient care quality. Participants emphasized that poor financial decisions could lead to staff burnout and compromised patient safety. The integration of both datasets provided a holistic perspective, ensuring that numerical trends were supported by real-world experiences.

This triangulation approach strengthened the study’s credibility and depth, demonstrating how financial management practices impact hospital operations and patient outcomes. The findings suggest that enhanced financial training and broader involvement in budgetary decisions could improve nurse leaders’ ability to manage resources effectively while maintaining care quality.

The study found that budgeting proficiency among nurse leaders was moderate (Mean = 3.90 ± 0.50), indicating variability in financial management skills. While some nurse leaders demonstrated competence in budgeting, qualitative findings revealed significant challenges related to limited financial training and unclear budget policies, which hindered their ability to effectively allocate funds. Participants expressed concerns that budget restrictions often forced them to make difficult trade-offs between staffing, equipment purchases, and operational costs, ultimately affecting healthcare service delivery. These findings suggest that structured financial training programs could enhance nurse leaders’ budgeting skills, enabling them to make more informed financial decisions. The results of other studies align with our findings. For instance, Paarima et al. [21] conducted a study in Ghana that assessed the financial management skills of nurse managers in the eastern region of Ghana. It demonstrated that nurses perceive moderate financial competencies. Similarly, Welch [22] explored whether nurse managers feel competent in the financial and business aspects of their roles and found that the strongest predictors of self-perceived financial competence were continuing education and MSN degrees. On the other hand, the present results contradict Sharma et al. [23], who evaluated a training program for life skills education and financial literacy for community health workers in India and reported that the majority of participants exhibited low financial competencies prior to the program.

Cost-effectiveness had a relatively high rating (Mean = 4.05 ± 0.45), reflecting nurse leaders’ ability to implement strategic cost-saving measures while maintaining operational efficiency. Qualitative findings validated this by showing that nurse leaders actively optimized staff scheduling, negotiated supplier contracts, and minimized waste to control hospital expenses. However, some participants expressed concerns that balancing cost-efficiency with maintaining care quality remained a constant challenge. Cost-cutting measures, if not carefully planned, could lead to resource shortages and reduced service availability, potentially compromising patient safety and treatment effectiveness. These findings highlight the importance of financial literacy in enabling nurse leaders to balance economic constraints with patient-centered care. Paarima et al. [21] also found a positive correlation between nurses’ perceptions of financial skills and the quality of patient care. Similarly, McFarlan [24] noted a positive relationship between nurse managers’ knowledge of healthcare financial management and their quality-of-care level in their units. Conversely, the present study’s findings oppose the results of Naranjee et al. [9], who reported that financial management roles of nurse managers in selected public hospitals in KwaZulu-Natal, South Africa, did not directly impact patient care but instead focused on staff nurses’ practices.

Decision-making influence received the highest mean score (4.10 ± 0.48), with qualitative responses confirming that senior nurse leaders felt empowered in financial decision-making, while those in lower positions had limited involvement in budgetary planning. Participants emphasized that nurse managers and unit-level leaders often had minimal influence over financial decisions, despite their direct responsibility for patient care. This discrepancy suggests a hierarchical gap in financial leadership, where financial authority is concentrated at higher administrative levels, limiting frontline leaders’ ability to advocate for resource allocations that directly impact patient care. Expanding financial decision-making opportunities across all leadership levels may improve resource distribution, enhance efficiency, and foster a culture of financial accountability within healthcare organizations. Töre and Uysal [25] reported that significant positive correlation was found between school principals’ empowering leadership characteristics and teachers’ participation in decision-making. Also, McFarlan [24] found that an experiential educational intervention improved nurse managers’ knowledge and self-assessed competence with healthcare financial management.

Resource allocation received a slightly lower score (Mean = 3.85 ± 0.55), with qualitative data highlighting nurse leaders’ frustrations over financial constraints and limited decision-making authority. Many participants reported that financial decisions were primarily controlled by hospital administrators, restricting their ability to distribute resources based on patient needs. This lack of autonomy often led to delays in purchasing essential medical supplies, understaffing, and operational inefficiencies. The integration of findings underscores the need for greater involvement of nurse leaders in financial decision-making, ensuring that budget al.locations align with clinical priorities to enhance patient care outcomes. Paarima et al. [21] similarly observed that budgetary constraints hindered nurse managers’ ability to secure essential resources in healthcare settings, especially in units like emergency care, where immediate access to resources is critical. Brydges et al. [26] similarly reported that nurse leaders need better education on the application of financial knowledge and practices to improve resource distribution in hospitals [26].

The study confirms that financial management practices have a direct impact on patient care outcomes (Mean = 3.95 ± 0.47). Qualitative findings reinforced that financial constraints, including staff shortages and limited medical supplies, negatively affected patient safety and treatment quality. Participants emphasized that poor financial decisions often resulted in staff burnout, delayed treatments, and compromised patient safety. These results underscore the critical role of financial management in ensuring safe, high-quality healthcare services. Ensuring that nurse leaders have adequate financial knowledge and decision-making authority can significantly improve hospital efficiency, patient outcomes, and overall care quality. Similarly, Otoo [27] also noted the impact of financial management practices on organizational performance and patient safety. Zhang & Bohlen [28] emphasized the importance of balancing healthcare business budgeting with maintaining care standards to avoid diminishing patient outcomes.

The study also found that age was a significant factor, with older nurse leaders—particularly those aged 35–40 and over 40—demonstrating higher levels of financial management proficiency. Chief nursing officers and nurse managers displayed the highest proficiency levels in financial management, likely attributed to their experience and roles involving direct involvement in budget planning, resource allocation, and cost-effectiveness measures. Bayram et al. [29] similarly noted a positive relationship between nurses’ demographic characteristics and their financial competencies. Additionally, Sharma et al. [23] found that socio-demographic attributes, such as age and experience, were associated with financial literacy among community health workers.

Our findings illustrated that 87.3% of nurse managers perceive a strong connection between financial management practices and patient care outcomes, underscoring the critical role of effective financial management in healthcare quality and efficiency. This high percentage suggests that nurse managers recognize financial decision-making as an essential component of hospital operations, directly impacting staffing, resource availability, and patient safety. These results supported with thev study by Homauni et al. [30] emphasized the role of budgeting in improving care standards and outcomes, while inadequate budgeting was found to compromise patient safety and satisfaction [30].

To support nurse leaders in improving financial competencies, healthcare institutions should: Incorporate formal financial training into academic curricula and continuing education programs tailored for nursing leaders. Facilitate active participation of nurse leaders in financial decision-making processes, particularly in budget planning and resource allocation, to promote patient-centered care. Develop frameworks that enable nurse leaders to balance cost-efficiency with maintaining high care standards. Provide organizational support and mentorship to nurse leaders, enabling them to navigate financial challenges and advocate for resources that align with patient needs.

First, the sample was limited to nurse leaders in private hospitals in Egypt, which may restrict the generalizability of findings to public healthcare settings or other regions. Future research should include a more diverse sample across various healthcare institutions to enhance applicability. Second, the cross-sectional design captures perceptions at a single point in time, limiting insights into long-term trends or the evolving impact of financial training on nurse leaders’ competencies. A longitudinal study could provide a deeper understanding of how financial literacy develops over time and its sustained impact on hospital efficiency. Additionally, self-reported data may introduce social desirability bias, as participants might have overestimated their financial management capabilities. Combining self-assessments with objective financial performance indicators could strengthen the reliability of findings.