Managerial Competency of First Line Nurse Managers and Its Impact on Nurses’ Retention and Quality of Care at King Fahad Central Hospital

Abstract

Abstract Background: Enhanced competencies in nurse managers, particularly in leadership and staff support, contribute to better nurse retention rates and improved patient care outcomes and quality of care. This suggests that investing in nurse manager training could benefit both nurses and the healthcare system as a whole. Aim: to assess managerial competency of first line nurse managers and its impact on nurses’ retention and quality of care at King Fahad Central Hospital Method: Descriptive correlational design, conducted at all inpatient departments of King Fahad Central Hospital, Jazan, Abu Arish, KSA, a Convenient sample (n=109) and 202 patients. Tools of data collection namely Tool (I): First-Line Nurse Managers' Managerial Competency Scale: Tool (II): Nurses’ Retention Scale Tool (III): The Karen-patient Instrument. Results: more than half (51.4%) of studied staff nurses, had high level of perception of managerial competency, the majority (79.8%) of studied staff nurses, had a high level of perception of nurses' retention whereas (20.2%) had a moderate level. As well as the majority (89.6%) of studied patients, had high level of quality-of-care perception whereas (10.4%) had moderate level, Furthermore, a statistically significant positive correlation was found between total management competency and nurses' retention, and a statistically significant positive correlation was found between total managerial competency and care quality. Conclusion: Depending on the findings of the study, It was determined that over half of the staff nurses in the study had high levels of nurses' retention and management competency perceptions, while also having high levels of patient-perceived quality of care. Recommendations: Developing structured programs to strengthen nurse managers' competencies in leadership, communication, and team motivation to positively impact retention and quality of care. Participating in professional development by engaging in training and workshops that improve both clinical and managerial skills Keywords First Line Nurse Managers, King Fahad Central Hospital, Managerial Competency - Nurses’ Retention, Quality of CareIntroduction First-line nurse managers are responsible for overseeing nursing staff and operations on the front line of patient care. They hold critical roles that involve leadership, staffing, and effective management to ensure high-quality patient care. Their responsibilities also extend to manag human resources and facilitating evidence-based practices within their teams. First line nurse managers are professional nurses who haves a multifaceted role in translating organizational strategic mission, values, and objectives into action at the unit level (Gunawan, et al., 2023). First-line managers are the entry-level managers who perform on-the-ground management duties. They are the managers who have the closest proximity with team members, and they are typically responsible for ensuring that their team effectively carries out organizational goals on a daily basis. Nurse managers work with their staff to coordinate all aspects of daily patient care in the unit. By ensuring that staff, patients, and patients' families are communicating, nurse managers help unit staff members deliver the safest possible care (Iblasi, et al., 2024). First-line nurse managers require high managerial competence to effectively deliver healthcare. Key attributes of this competence include self-development, planning, organizing, leading, managing legal and ethical issues, and ensuring quality care delivery. Their competency significantly influences staff engagement and overall team performance in healthcare settings. Management competency of first- line nurse managers include leadership, facilitation of spiritual nursing, self- management, staffing and professional development, use of information technology, financial management and, finally, improvement of quality care (Marzilli, & BC, 2023). First-line nurse managers have complex roles in health care. They need to be responsible for translating strategic goals and objectives formulated at the operational level into practice and for providing not only administrative and clinical leadership but also holding 24-hour accountability for all patient care activities on the unit. A variety of terms are used interchangeably to define managerial competence of first-line nurse managers. This has resulted in a degree of ambiguity in the way managerial competence is described (Perez-Gonzalez, et al., 2024). First-line nurse managers also need to act as a leader who plays a pivotal role in the lives of registered nurses that is essential in ensuring quality client outcomes and are required to have an ability to interpret general concepts and integrate them into specific clinical and managerial performance while also determining and monitoring outcomes. Nowadays, health care has undergone a process of decentralization, and the role of FLNMs has changed from clinical focus to managerial focus. It is required that competent FLNMs apply their managerial functions, which are called “managerial competence.” (Hussien, Adam, Hassan, & Abdrabou, 2023). Managerial competence in nursing refers to the ability of nurse managers to effectively lead and manage nursing staff, ensure quality patient care, and facilitate organizational goals. This competence encompasses a range of skills, knowledge, and attributes that contribute to the successful functioning of healthcare teams and the overall healthcare environment. Various attributes of managerial competences as leadership skills, communication skills, clinical knowledge, organizational skills, emotional intelligence, critical thinking and problem-solving, and advocacy (Fjordkvist, et al., 2024). Different skills are vital such as the ability to inspire and motivate staff, skill in conflict resolution and decision-making, proficient in verbal and written communication, ability to listen actively and provide clear instructions, strong understanding of nursing practices and patient care, up to date with clinical guidelines and evidence-based practices, ability to manage time effectively and prioritize tasks (Mirzaei, et al., 2024). Additionally, skills in resource allocation and budgeting, capacity to understand and manage one’s own emotions and those of others, empathy towards staff and patients to foster a supportive environment, ability to analyze situations and make informed decisions, skill in developing and implementing solutions to challenges, commitment to advocating for patients, staff, and the nursing profession, and ability to address ethical issues and promote a culture of safety (Al-Nasri, 2024). Antecedents of managerial competence include formal education in nursing management or administration, participation in leadership development programs, prior experience in clinical and managerial roles, exposure to diverse healthcare settings and situations, availability of mentorship and guidance from experienced leaders, access to professional development resources and training, a supportive culture that values leadership and management skills, encouragement of continuous learning and improvement, individual motivation and a desire for personal growth, and resilience and adaptability in facing challenges (Paarima, Kwashie, Asamani, & Ofei, 2022). Competent managers support the growth and development of their staff, facilitating ongoing education and training opportunities. Enhanced competencies in nurse managers, particularly in leadership and staff support, contribute. This suggests that investing in nurse manager training could benefit both nurses and the healthcare system as a whole (Gunawan, et al., 2020). Nurse retention is crucial in addressing high turnover rates in the healthcare sector. Key factors that influence nurse's retention include job satisfaction, organizational commitment, and effective recruitment strategies (Soliman, El-Bialy, & El-liethey, 2020). Improving these aspects can help reduce turnover and enhance nurse's morale. Nurse retention refers to the rate at which registered nurses stay employed by a healthcare organization over a given period of time. Addressing nurse turnover requires health care leaders to understand the factors contributing to it. This understanding can provide the insights needed to tackle the challenge head-on (Gunawan, Aungsuroch, Fisher, & McDaniel, 2020). Nurses account for almost 50% of the global healthcare workforce and their deficits pose the single biggest challenge for many healthcare systems. Nursing workforce shortages have far‐reaching and cumulative impacts on patient ratios, staff dissatisfaction, occupational stress and burnout and nurse's retention to the ultimate detriment of patient safety and quality of care. For every nurse that leaves there is a detrimental impact on the working experiences of nurses who remain when job pressures and workloads increase (Cardiff, Gershuni, & Giesbergen‐Brekelmans, 2023). High morale and job satisfaction make nursing staff more likely to stay with their organization. Positive feelings tend to increase motivation among nurses and foster a sense of loyalty and commitment. This, in turn, leads to higher retention rates and a more stable and skilled nursing workforce. nurse's recruitment and nurse's retention are intrinsically linked. Effective nurse's recruitment strategies play a critical role in building a strong and sustainable nursing workforce that, in turn, improves nurse's retention (Pressley, & Garside, 2023). Nurse leaders/ managers play a pivotal role in creating supportive, fulfilling environments that not only retain experienced nurses but also enhance patient care. By implementing effective nurse retention strategies, health care organizations can quell rising nurse turnover rates and lessen the negative impact that this problem has on the nursing profession. The nurse retention strategies below apply to various aspects of nursing workplace culture. Additionally, quality of care as understaffing can compromise the quality of patient care because nurses spend less time with each patient (Chang, & Cho, 2023). Caring expressed in nursing is the intended and actual presence of the nurse who is recognized as a person who is loving, caring and growing in caring. Caring involves tending to the patient’s needs, providing physical and spiritual well-being, and building trust. The concept of quality of care has been a theme of debate among the nurses of the scientific community for many years, as it has been associated with various dimensions of healthcare, such as interpersonal and technical aspects of care, patient outcomes, structure, processes, and the setting of quality standards (Wei, et al., 2023). Furthermore, patient satisfaction, safety, person-centered care, staff competency, and patient involvement in decision-making are some of the indicators of a high quality of care in clinical settings. Quality nursing care is viewed differently by healthcare professionals and patients. Therefore, competent nursing care is considered quality nursing care by healthcare professionals. Good interpersonal relationships and caring are perceived as quality nursing care (Dilas, et al., 2023). Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes. It is based on evidence-based professional knowledge and is critical for achieving universal health coverage. As countries commit to achieving health for all, it is imperative to carefully consider the quality of care and health services. Moreover, quality care appears to be a multidimensional issue involving a list of various features that depend on the level of the healthcare delivered, the health system’s goals and performance, and on stakeholders’ views and personal assessment (Moons, et al., 2023). Quality health care can be defined in many ways but there is growing acknowledgement that quality health services should be effective through providing evidence-based healthcare services to those who need them, safe as avoiding harm to people for whom the care is intended; and people-centered through providing care that responds to individual preferences, needs and values. Quality health care ensuring that the right actions are taken at the right time and in the right manner (Alharbi, et al., 2023). To realize the benefits of quality health care, health services must be timely which meaning reducing waiting times and sometimes harmful delays, equitable by providing care that does not vary in quality on account of gender, ethnicity, geographic location, and socio-economic status, integrated as providing care that makes available the full range of health services throughout the life course, and efficient by maximizing the benefit of available resources and avoiding waste (Labrague, & de Los Santos, 2021). As contemporary healthcare systems focus on the patient for achieving a high quality of services, factors such as personalized care, nurses’ responsiveness to patient requests, an effective patient –nurse ratio, adequate information, and accessibility were valued as important dimensions of quality care and patient satisfaction. In addition, healthcare-quality interventions focusing upon patient outcomes and new conceptual frameworks for quality and outcomes research were developed (Pérez-Francisco, et al., 2020) Introduction First-line nurse managers are responsible for overseeing nursing staff and operations on the front line of patient care. They hold critical roles that involve leadership, staffing, and effective management to ensure high-quality patient care. Their responsibilities also extend to manag human resources and facilitating evidence-based practices within their teams. First line nurse managers are professional nurses who haves a multifaceted role in translating organizational strategic mission, values, and objectives into action at the unit level (Gunawan, et al., 2023). First-line managers are the entry-level managers who perform on-the-ground management duties. They are the managers who have the closest proximity with team members, and they are typically responsible for ensuring that their team effectively carries out organizational goals on a daily basis. Nurse managers work with their staff to coordinate all aspects of daily patient care in the unit. By ensuring that staff, patients, and patients' families are communicating, nurse managers help unit staff members deliver the safest possible care (Iblasi, et al., 2024). First-line nurse managers require high managerial competence to effectively deliver healthcare. Key attributes of this competence include self-development, planning, organizing, leading, managing legal and ethical issues, and ensuring quality care delivery. Their competency significantly influences staff engagement and overall team performance in healthcare settings. Management competency of first- line nurse managers include leadership, facilitation of spiritual nursing, self- management, staffing and professional development, use of information technology, financial management and, finally, improvement of quality care (Marzilli, & BC, 2023). First-line nurse managers have complex roles in health care. They need to be responsible for translating strategic goals and objectives formulated at the operational level into practice and for providing not only administrative and clinical leadership but also holding 24-hour accountability for all patient care activities on the unit. A variety of terms are used interchangeably to define managerial competence of first-line nurse managers. This has resulted in a degree of ambiguity in the way managerial competence is described (Perez-Gonzalez, et al., 2024). First-line nurse managers also need to act as a leader who plays a pivotal role in the lives of registered nurses that is essential in ensuring quality client outcomes and are required to have an ability to interpret general concepts and integrate them into specific clinical and managerial performance while also determining and monitoring outcomes. Nowadays, health care has undergone a process of decentralization, and the role of FLNMs has changed from clinical focus to managerial focus. It is required that competent FLNMs apply their managerial functions, which are called “managerial competence.” (Hussien, Adam, Hassan, & Abdrabou, 2023). Managerial competence in nursing refers to the ability of nurse managers to effectively lead and manage nursing staff, ensure quality patient care, and facilitate organizational goals. This competence encompasses a range of skills, knowledge, and attributes that contribute to the successful functioning of healthcare teams and the overall healthcare environment. Various attributes of managerial competences as leadership skills, communication skills, clinical knowledge, organizational skills, emotional intelligence, critical thinking and problem-solving, and advocacy (Fjordkvist, et al., 2024). Different skills are vital such as the ability to inspire and motivate staff, skill in conflict resolution and decision-making, proficient in verbal and written communication, ability to listen actively and provide clear instructions, strong understanding of nursing practices and patient care, up to date with clinical guidelines and evidence-based practices, ability to manage time effectively and prioritize tasks (Mirzaei, et al., 2024). Additionally, skills in resource allocation and budgeting, capacity to understand and manage one’s own emotions and those of others, empathy towards staff and patients to foster a supportive environment, ability to analyze situations and make informed decisions, skill in developing and implementing solutions to challenges, commitment to advocating for patients, staff, and the nursing profession, and ability to address ethical issues and promote a culture of safety (Al-Nasri, 2024). Antecedents of managerial competence include formal education in nursing management or administration, participation in leadership development programs, prior experience in clinical and managerial roles, exposure to diverse healthcare settings and situations, availability of mentorship and guidance from experienced leaders, access to professional development resources and training, a supportive culture that values leadership and management skills, encouragement of continuous learning and improvement, individual motivation and a desire for personal growth, and resilience and adaptability in facing challenges (Paarima, Kwashie, Asamani, & Ofei, 2022). Competent managers support the growth and development of their staff, facilitating ongoing education and training opportunities. Enhanced competencies in nurse managers, particularly in leadership and staff support, contribute. This suggests that investing in nurse manager training could benefit both nurses and the healthcare system as a whole (Gunawan, et al., 2020). Nurse retention is crucial in addressing high turnover rates in the healthcare sector. Key factors that influence nurse's retention include job satisfaction, organizational commitment, and effective recruitment strategies (Soliman, El-Bialy, & El-liethey, 2020). Improving these aspects can help reduce turnover and enhance nurse's morale. Nurse retention refers to the rate at which registered nurses stay employed by a healthcare organization over a given period of time. Addressing nurse turnover requires health care leaders to understand the factors contributing to it. This understanding can provide the insights needed to tackle the challenge head-on (Gunawan, Aungsuroch, Fisher, & McDaniel, 2020). Nurses account for almost 50% of the global healthcare workforce and their deficits pose the single biggest challenge for many healthcare systems. Nursing workforce shortages have far‐reaching and cumulative impacts on patient ratios, staff dissatisfaction, occupational stress and burnout and nurse's retention to the ultimate detriment of patient safety and quality of care. For every nurse that leaves there is a detrimental impact on the working experiences of nurses who remain when job pressures and workloads increase (Cardiff, Gershuni, & Giesbergen‐Brekelmans, 2023). High morale and job satisfaction make nursing staff more likely to stay with their organization. Positive feelings tend to increase motivation among nurses and foster a sense of loyalty and commitment. This, in turn, leads to higher retention rates and a more stable and skilled nursing workforce. nurse's recruitment and nurse's retention are intrinsically linked. Effective nurse's recruitment strategies play a critical role in building a strong and sustainable nursing workforce that, in turn, improves nurse's retention (Pressley, & Garside, 2023). Nurse leaders/ managers play a pivotal role in creating supportive, fulfilling environments that not only retain experienced nurses but also enhance patient care. By implementing effective nurse retention strategies, health care organizations can quell rising nurse turnover rates and lessen the negative impact that this problem has on the nursing profession. The nurse retention strategies below apply to various aspects of nursing workplace culture. Additionally, quality of care as understaffing can compromise the quality of patient care because nurses spend less time with each patient (Chang, & Cho, 2023). Caring expressed in nursing is the intended and actual presence of the nurse who is recognized as a person who is loving, caring and growing in caring. Caring involves tending to the patient’s needs, providing physical and spiritual well-being, and building trust. The concept of quality of care has been a theme of debate among the nurses of the scientific community for many years, as it has been associated with various dimensions of healthcare, such as interpersonal and technical aspects of care, patient outcomes, structure, processes, and the setting of quality standards (Wei, et al., 2023). Furthermore, patient satisfaction, safety, person-centered care, staff competency, and patient involvement in decision-making are some of the indicators of a high quality of care in clinical settings. Quality nursing care is viewed differently by healthcare professionals and patients. Therefore, competent nursing care is considered quality nursing care by healthcare professionals. Good interpersonal relationships and caring are perceived as quality nursing care (Dilas, et al., 2023). Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes. It is based on evidence-based professional knowledge and is critical for achieving universal health coverage. As countries commit to achieving health for all, it is imperative to carefully consider the quality of care and health services. Moreover, quality care appears to be a multidimensional issue involving a list of various features that depend on the level of the healthcare delivered, the health system’s goals and performance, and on stakeholders’ views and personal assessment (Moons, et al., 2023). Quality health care can be defined in many ways but there is growing acknowledgement that quality health services should be effective through providing evidence-based healthcare services to those who need them, safe as avoiding harm to people for whom the care is intended; and people-centered through providing care that responds to individual preferences, needs and values. Quality health care ensuring that the right actions are taken at the right time and in the right manner (Alharbi, et al., 2023). To realize the benefits of quality health care, health services must be timely which meaning reducing waiting times and sometimes harmful delays, equitable by providing care that does not vary in quality on account of gender, ethnicity, geographic location, and socio-economic status, integrated as providing care that makes available the full range of health services throughout the life course, and efficient by maximizing the benefit of available resources and avoiding waste (Labrague, & de Los Santos, 2021). As contemporary healthcare systems focus on the patient for achieving a high quality of services, factors such as personalized care, nurses’ responsiveness to patient requests, an effective patient –nurse ratio, adequate information, and accessibility were valued as important dimensions of quality care and patient satisfaction. In addition, healthcare-quality interventions focusing upon patient outcomes and new conceptual frameworks for quality and outcomes research were developed (Pérez-Francisco, et al., 2020) Significance of the Study Managerial competency of nurse managers is believed to influence the efficiency of healthcare. Within the global shortage of nurses and the rising cost of healthcare, it is imperative to assess the managerial competency of nurse managers (Cox, 2023). The application of competencies is now a leading organizational strategy in all major human resource areas. Competency is the building blocks of work performance, and performance consists of many features of practice, cognitive, affective and psychomotor skills (González‐García, et al., 2021). The relationship between commercial and sustainability policies with respect to offering quality care in health systems is the starting point to justify the development of managerial competency; these competency are necessary for a higher degree of performance and results as the development of an advanced level of managerial competencies is fundamental in achieving the objectives of the organization and the capacity of the nurse manager to develop advanced competencies in management as one of the key strategies for the success of health organizations (Filomeno, et al., 2024). The improvement of administration competency and quality of care might strategically and systematically enhance all authoritative and essential management functions and will guide development and preparing and competent managers and leaders. Nurse retention is a critical issue in healthcare systems worldwide, directly impacting patient care, organizational performance, and overall healthcare quality. As the demand for skilled nursing professionals increases, understanding the relationship between nursing competency and retention becomes essential. Introduction First-line nurse managers are responsible for overseeing nursing staff and operations on the front line of patient care. They hold critical roles that involve leadership, staffing, and effective management to ensure high-quality patient care. Their responsibilities also extend to manag human resources and facilitating evidence-based practices within their teams. First line nurse managers are professional nurses who haves a multifaceted role in translating organizational strategic mission, values, and objectives into action at the unit level (Gunawan, et al., 2023). First-line managers are the entry-level managers who perform on-the-ground management duties. They are the managers who have the closest proximity with team members, and they are typically responsible for ensuring that their team effectively carries out organizational goals on a daily basis. Nurse managers work with their staff to coordinate all aspects of daily patient care in the unit. By ensuring that staff, patients, and patients' families are communicating, nurse managers help unit staff members deliver the safest possible care (Iblasi, et al., 2024). First-line nurse managers require high managerial competence to effectively deliver healthcare. Key attributes of this competence include self-development, planning, organizing, leading, managing legal and ethical issues, and ensuring quality care delivery. Their competency significantly influences staff engagement and overall team performance in healthcare settings. Management competency of first- line nurse managers include leadership, facilitation of spiritual nursing, self- management, staffing and professional development, use of information technology, financial management and, finally, improvement of quality care (Marzilli, & BC, 2023). First-line nurse managers have complex roles in health care. They need to be responsible for translating strategic goals and objectives formulated at the operational level into practice and for providing not only administrative and clinical leadership but also holding 24-hour accountability for all patient care activities on the unit. A variety of terms are used interchangeably to define managerial competence of first-line nurse managers. This has resulted in a degree of ambiguity in the way managerial competence is described (Perez-Gonzalez, et al., 2024). First-line nurse managers also need to act as a leader who plays a pivotal role in the lives of registered nurses that is essential in ensuring quality client outcomes and are required to have an ability to interpret general concepts and integrate them into specific clinical and managerial performance while also determining and monitoring outcomes. Nowadays, health care has undergone a process of decentralization, and the role of FLNMs has changed from clinical focus to managerial focus. It is required that competent FLNMs apply their managerial functions, which are called “managerial competence.” (Hussien, Adam, Hassan, & Abdrabou, 2023). Managerial competence in nursing refers to the ability of nurse managers to effectively lead and manage nursing staff, ensure quality patient care, and facilitate organizational goals. This competence encompasses a range of skills, knowledge, and attributes that contribute to the successful functioning of healthcare teams and the overall healthcare environment. Various attributes of managerial competences as leadership skills, communication skills, clinical knowledge, organizational skills, emotional intelligence, critical thinking and problem-solving, and advocacy (Fjordkvist, et al., 2024). Different skills are vital such as the ability to inspire and motivate staff, skill in conflict resolution and decision-making, proficient in verbal and written communication, ability to listen actively and provide clear instructions, strong understanding of nursing practices and patient care, up to date with clinical guidelines and evidence-based practices, ability to manage time effectively and prioritize tasks (Mirzaei, et al., 2024). Additionally, skills in resource allocation and budgeting, capacity to understand and manage one’s own emotions and those of others, empathy towards staff and patients to foster a supportive environment, ability to analyze situations and make informed decisions, skill in developing and implementing solutions to challenges, commitment to advocating for patients, staff, and the nursing profession, and ability to address ethical issues and promote a culture of safety (Al-Nasri, 2024). Antecedents of managerial competence include formal education in nursing management or administration, participation in leadership development programs, prior experience in clinical and managerial roles, exposure to diverse healthcare settings and situations, availability of mentorship and guidance from experienced leaders, access to professional development resources and training, a supportive culture that values leadership and management skills, encouragement of continuous learning and improvement, individual motivation and a desire for personal growth, and resilience and adaptability in facing challenges (Paarima, Kwashie, Asamani, & Ofei, 2022). Competent managers support the growth and development of their staff, facilitating ongoing education and training opportunities. Enhanced competencies in nurse managers, particularly in leadership and staff support, contribute. This suggests that investing in nurse manager training could benefit both nurses and the healthcare system as a whole (Gunawan, et al., 2020). Nurse retention is crucial in addressing high turnover rates in the healthcare sector. Key factors that influence nurse's retention include job satisfaction, organizational commitment, and effective recruitment strategies (Soliman, El-Bialy, & El-liethey, 2020). Improving these aspects can help reduce turnover and enhance nurse's morale. Nurse retention refers to the rate at which registered nurses stay employed by a healthcare organization over a given period of time. Addressing nurse turnover requires health care leaders to understand the factors contributing to it. This understanding can provide the insights needed to tackle the challenge head-on (Gunawan, Aungsuroch, Fisher, & McDaniel, 2020). Nurses account for almost 50% of the global healthcare workforce and their deficits pose the single biggest challenge for many healthcare systems. Nursing workforce shortages have far‐reaching and cumulative impacts on patient ratios, staff dissatisfaction, occupational stress and burnout and nurse's retention to the ultimate detriment of patient safety and quality of care. For every nurse that leaves there is a detrimental impact on the working experiences of nurses who remain when job pressures and workloads increase (Cardiff, Gershuni, & Giesbergen‐Brekelmans, 2023). High morale and job satisfaction make nursing staff more likely to stay with their organization. Positive feelings tend to increase motivation among nurses and foster a sense of loyalty and commitment. This, in turn, leads to higher retention rates and a more stable and skilled nursing workforce. nurse's recruitment and nurse's retention are intrinsically linked. Effective nurse's recruitment strategies play a critical role in building a strong and sustainable nursing workforce that, in turn, improves nurse's retention (Pressley, & Garside, 2023). Nurse leaders/ managers play a pivotal role in creating supportive, fulfilling environments that not only retain experienced nurses but also enhance patient care. By implementing effective nurse retention strategies, health care organizations can quell rising nurse turnover rates and lessen the negative impact that this problem has on the nursing profession. The nurse retention strategies below apply to various aspects of nursing workplace culture. Additionally, quality of care as understaffing can compromise the quality of patient care because nurses spend less time with each patient (Chang, & Cho, 2023). Caring expressed in nursing is the intended and actual presence of the nurse who is recognized as a person who is loving, caring and growing in caring. Caring involves tending to the patient’s needs, providing physical and spiritual well-being, and building trust. The concept of quality of care has been a theme of debate among the nurses of the scientific community for many years, as it has been associated with various dimensions of healthcare, such as interpersonal and technical aspects of care, patient outcomes, structure, processes, and the setting of quality standards (Wei, et al., 2023). Furthermore, patient satisfaction, safety, person-centered care, staff competency, and patient involvement in decision-making are some of the indicators of a high quality of care in clinical settings. Quality nursing care is viewed differently by healthcare professionals and patients. Therefore, competent nursing care is considered quality nursing care by healthcare professionals. Good interpersonal relationships and caring are perceived as quality nursing care (Dilas, et al., 2023). Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes. It is based on evidence-based professional knowledge and is critical for achieving universal health coverage. As countries commit to achieving health for all, it is imperative to carefully consider the quality of care and health services. Moreover, quality care appears to be a multidimensional issue involving a list of various features that depend on the level of the healthcare delivered, the health system’s goals and performance, and on stakeholders’ views and personal assessment (Moons, et al., 2023). Quality health care can be defined in many ways but there is growing acknowledgement that quality health services should be effective through providing evidence-based healthcare services to those who need them, safe as avoiding harm to people for whom the care is intended; and people-centered through providing care that responds to individual preferences, needs and values. Quality health care ensuring that the right actions are taken at the right time and in the right manner (Alharbi, et al., 2023). To realize the benefits of quality health care, health services must be timely which meaning reducing waiting times and sometimes harmful delays, equitable by providing care that does not vary in quality on account of gender, ethnicity, geographic location, and socio-economic status, integrated as providing care that makes available the full range of health services throughout the life course, and efficient by maximizing the benefit of available resources and avoiding waste (Labrague, & de Los Santos, 2021). As contemporary healthcare systems focus on the patient for achieving a high quality of services, factors such as personalized care, nurses’ responsiveness to patient requests, an effective patient –nurse ratio, adequate information, and accessibility were valued as important dimensions of quality care and patient satisfaction. In addition, healthcare-quality interventions focusing upon patient outcomes and new conceptual frameworks for quality and outcomes research were developed (Pérez-Francisco, et al., 2020)

Aim of the Study The aim of this study was to assess the managerial competency of first line nurse managers and its impact on nurses’ retention and quality of care at King Fahad Central Hospital through: Research Questions: Q1: What are the levels staff nurses' perception regarding their managerial competency of first line nurse manager at King Fahad Central Hospital? Q2: What are the levels of nurses' retention at King Fahad Central Hospital? Q3: What are the levels of quality of care as perceived by patients at King Fahad Central Hospital? Q4: What is the effect of first line nurse managers' managerial competency on nurses’ retention and quality of care at King Fahad Central Hospital, Saudi Arabia?

Literature Review Nurse managers work with their staff to coordinate all aspects of daily patient care in the unit. First line nurse managers (FLNMs) are professional nurses who haves a multifaceted role in translating organizational strategic mission, values, and objectives into action at the unit level (Gunawan, et al., 2023). They are the managers who have the closest proximity with team members, and they are typically responsible for ensuring that their team effectively carries out organizational goals on a daily basis. First-line nurse managers require high managerial competence to effectively deliver healthcare (Iblasi, et al., 2024). For instance, managerial competence is described as a combination of knowledge, skills, abilities, and behaviors that nurses use in an organization. Another definition refers to the ability of the person (nurses) to perform their job. The terms “competence,” “competency,” and “skill” are often used interchangeably (Filomeno, et al., 2024). Nurse leaders/ managers play a pivotal role in creating supportive, fulfilling environments that not only retain experienced nurses but also enhance patient care. By implementing effective nurse retention strategies, health care organizations can quell rising nurse turnover rates and lessen the negative impact that this problem has on the nursing profession. The nurse retention strategies below apply to various aspects of nursing workplace culture. Additionally, quality of care as understaffing can compromise the quality of patient care because nurses spend less time with each patient (Chang, & Cho, 2023). Definition of managerial nursing competencies Managerial competence in nursing refers to the ability of nurse managers to effectively lead and manage nursing staff, ensure quality patient care, and facilitate organizational goals. This competence encompasses a range of skills, knowledge, and attributes that contribute to the successful functioning of healthcare teams and the overall healthcare environment. Various attributes of managerial competences as leadership skills, communication skills, clinical knowledge, organizational skills, emotional intelligence, critical thinking and problem-solving, and advocacy (Fjordkvist, et al., 2024). Managerial nursing competencies imply the knowledge, skills, and abilities that nurses must possess to effectively manage healthcare teams and deliver high-quality patient care. These competencies encompass both clinical expertise and management skills necessary for leading nursing staff, coordinating care, and improving healthcare delivery systems. A well-defined set of managerial competencies is crucial for the success of nursing leaders and the organizations they serve (Filomeno, et al., 2024). Managerial nursing competencies refer to the essential skills, knowledge, and behaviors that nurse managers must possess to effectively lead nursing teams and ensure high-quality patient care. These competencies encompass a wide range of areas, including clinical expertise, leadership, communication, financial management, and human resource management. The ability to integrate these competencies allows nurse managers to navigate the complexities of healthcare environments, make informed decisions, and foster a culture of excellence within their teams (Shurab, et al., 2024). Principles of managerial nursing competencies The principles underlying managerial nursing competencies emphasize the importance of holistic leadership in healthcare. First, effective nurse managers must prioritize patient-centered care, ensuring that all decisions and actions align with improving patient outcomes. Second, they must cultivate a collaborative work environment that encourages teamwork and open communication among staff members. Third, ethical decision-making is paramount; nurse managers should uphold legal and ethical standards while advocating for both patients and staff. Lastly, continuous professional development is essential; nurse managers should engage in lifelong learning to adapt to evolving healthcare trends and practices (Hariyati, et al., 2024). As well as patient-centered care, evidence-based practice, collaboration and teamwork, continuous improvement is considered among the underlying principles of managerial nursing competencies. as patient-centered care; prioritizing the needs and preferences of patients in all management decisions, evidence-based practice; utilizing current research and best practices to guide management decisions. Collaboration and teamwork as fostering a collaborative environment among healthcare professionals to enhance patient outcomes. Continuous improvement by committing to ongoing professional development and quality improvement initiatives (Shurab, Ibrahim, Abdelaalem, Gabal, & Abdelhady, 2024). Components of managerial nursing competencies Effective leadership skills involve motivating and inspiring staff, fostering a positive work environment, facilitating professional growth among team members, and guiding and inspiring nursing teams to achieve common goals. Effectively conveying information and fostering open dialogue among staff and stakeholders. Clear and effective communication skills are vital for coordinating care, resolving conflicts, and building relationships with both staff and patients (Mozzarelli, Catinella, & Tuccio, 2024). Clinical competence nurse managers must possess a strong foundation in clinical knowledge to guide their teams effectively and ensure high standards of patient care. Decision-making is done through analyzing data, assessing situations, and making informed choices that impact patient care and staff performance. Financial management as nurse managers should understand budgeting, resource allocation, and financial planning to ensure efficient use of organizational resources. Resource management efficiently for human, financial, and material resources to optimize care delivery. Human resource management includes staffing, performance evaluations, conflict resolution, and nurses development strategies to enhance team performance. Quality assurance by implementing systems to monitor and improve the quality of care provided (Önal, & Seren İntepeler, 2024).

Fig 1: Exploring the core competencies of clinical nurses in chinese tertiary

influence competency development, and the level of education attained by nurse managers significantly impacts their knowledge base and ability to perform managerial functions effectively. work environment as supportive organizational cultures that prioritize professional development can enhance nurses' opportunities to develop their competencies. Access to leadership training programs equips nurse managers with the necessary skills to excel in their roles. Practical experience in clinical and managerial roles enhances competency (Ivziku, et al., 2024). Mentorship opportunities guidance from experienced leaders can facilitate the growth of managerial competencies among aspiring nurse managers. Personal motivation, individual ambition and commitment to professional growth play a crucial role in developing managerial skills. A supportive organizational culture fosters the development and application of competencies. Access to and proficiency in healthcare technology can impact management effectiveness. Changes in healthcare policies and regulation can influence the scope and nature of nursing management roles (Abadian, Alavi, & Tagharrobi, 2024). Influence of Internal and External Factors on Managerial Nursing Competencies Internal Factors Internal factors refer to the elements within the organization that influence managerial nursing competencies. These include individual characteristics such as educational background, work experience, and personal attributes like confidence and resilience. For instance, a nurse manager's educational level significantly impacts their ability to make informed decisions and lead effectively. Higher education often correlates with enhanced critical thinking skills and a deeper understanding of healthcare systems, which are essential for effective management (Chen, et al 2024). Additionally, work experience plays a crucial role in shaping managerial competencies. Nurses with extensive clinical experience are typically more adept at understanding the complexities of patient care, which informs their decision-making and leadership styles. Personal attributes such as confidence and emotional intelligence also contribute to a nurse manager's effectiveness. Managers who possess high levels of self-efficacy are more likely to take initiative, motivate their teams, and handle challenges effectively (Araújo, Peduzzi, Mazzi, Souza, & Leonello, 2023). Furthermore, organizational culture is an internal factor that can either support or hinder the development of managerial competencies. A culture that promotes continuous learning and professional development encourages nurse managers to pursue further education and training, thereby enhancing their competencies. Conversely, a toxic work environment may lead to burnout and disengagement, negatively impacting the managerial capabilities of nursing leaders (Gunawan, Aungsuroch, Fisher, Marzilli, & Hastuti, 2023). External Factors External factors encompass influences outside the organization that affect managerial nursing competencies. These include regulatory requirements, healthcare policies, technological advancements, and economic conditions. For example, changes in healthcare regulations may necessitate additional training for nurse managers to ensure compliance with new standards. Similarly, advancements in technology require nurse managers to adapt quickly and develop competencies related to new tools and systems that improve patient care (Ndayishimiye, Dubas-Jakóbczyk, Holubenko, & Domagała, 2023). The healthcare environment itself is another external factor that influences managerial competencies. Competitive pressures from other healthcare organizations can drive nurse managers to enhance their skills in areas such as financial management and strategic planning to maintain their organization's market position. Additionally, external stakeholder expectations—such as those from patients, families, and regulatory bodies—can shape the competencies required for effective nursing management (Wiisak, et al., 2024). Moreover, collaboration with external organizations, such as educational institutions and professional associations, can provide valuable resources for developing managerial competencies. Partnerships with academic institutions can offer continuing education opportunities for nurse managers, while professional associations can provide networking opportunities and access to best practices in nursing leadership. (Swinton, & Haverkamp, 2023). Challenges of managerial nursing competencies Despite the presence of both internal and external factors that can enhance managerial nursing competencies, several challenges exist. One significant challenge is the rapid pace of change in healthcare, which can overwhelm nurse managers who must continuously adapt to new regulations, technologies, and practices. This constant need for adaptation can lead to stress and burnout among nursing leaders. Another challenge is the potential lack of support from upper management or insufficient resources allocated for professional development (González‐García, Pinto‐Carral, Pérez‐González, & Marqués‐Sánchez, 2021). Nurse managers may find it difficult to pursue further education or training if organizational priorities do not align with their professional growth needs. Additionally, high turnover rates among nursing staff can create instability within teams, making it challenging for nurse managers to implement consistent practices or develop cohesive leadership strategies. Lastly, balancing clinical responsibilities with managerial duties poses a significant challenge for many nurse managers. The demands of patient care often take precedence over administrative tasks, which can limit opportunities for skill enhancement in management areas such as budgeting or strategic planning (Ma, et al., 2020). Nurse managers face several challenges in developing and maintaining their managerial competencies including high workload, workplace stress, staff shortages resistance to change, limited resources, balancing clinical and managerial roles, and keeping up with rapid changes. As the demanding nature of nursing management can hinder opportunities for professional development due to time constraints, and insufficient staffing levels can lead to increased stress for nurse managers, making it difficult to focus on leadership development. High-stress environments can hinder effective management and decision-making, implementing new practices or policies may encounter resistance from staff members who are accustomed to established routines (Paarima, Kwashie, & Ansah Ofei, 2020). Staff resistance to new policies or practices can challenge the implementation of effective management strategies, budget constraints can restrict access to training programs or resources necessary for skill enhancement. nurse managers often struggle to balance their clinical responsibilities with their managerial duties, impacting their ability to develop leadership skills effectively. Striking a balance between direct patient care and managerial responsibilities can be difficult. Keeping up with rapid changes as the fast-paced nature of healthcare requires continual adaptation and learning. (Kukkonen, et al., 2020). Maintaining Managerial Competencies To maintain and enhance managerial nursing competencies amidst these challenges, organizations should prioritize ongoing education and professional development for nurse managers. This can include providing access to workshops, seminars, and online courses focused on leadership skills and healthcare management. Organizations should also foster a supportive work environment that encourages collaboration among nursing staff. Implementing mentorship programs where experienced nurse leaders guide newer managers can facilitate knowledge transfer and skill development (Ofei, Paarima, & Barnes, 2020). Furthermore, organizations need to invest in resources that support nurse managers in balancing their clinical responsibilities with administrative duties. This may involve hiring additional staff or utilizing technology to streamline administrative tasks. Lastly, creating a culture of feedback where nurse managers can regularly assess their performance and seek input from peers will promote continuous improvement in their competencies. By addressing both internal and external factors proactively, healthcare organizations can ensure that their nursing leaders are well-equipped to meet the demands of their roles effectively (Karsikas, et al., 2022). To maintain and enhance managerial nursing competencies, organizations can implement several strategies as continuous education by encourage ongoing education through workshops, seminars, and online courses and advanced degrees focused on leadership development and management skills. Regular performance evaluations through conduct assessments that provide feedback on managerial performance, identifying areas for improvement and setting goals for development (Srikanth, & Jomon, 2020). Establish mentorship programs initiatives that pair experienced nurse leaders with emerging leaders to facilitate knowledge transfer and skill development. Encourage networking and promote participation in professional organizations where nurse managers can share experiences, challenges, and best practices with peers. Foster a culture of learning and create an organizational culture that values continuous improvement by recognizing efforts toward professional growth and encouraging innovation among nursing staff (Moradi, et al., 2020). Managerial nursing competencies are essential for effective leadership in healthcare settings. By understanding these strategies for maintenance, healthcare organizations can empower their nursing leaders to excel in their roles. Investing in the development of these competencies not only enhances the effectiveness of nurse managers but also contributes significantly to improved patient outcomes and overall organizational success (Ozmen, & Arslan Yurumezoglu, 2022). Competent managers support the growth and development of their staff, facilitating ongoing education and training opportunities. There is a significant relationship between nurse manager competencies and nurses' retention. Enhanced competencies in nurse managers, particularly in leadership and staff support, contribute to better nurse retention rates and improved patient care outcomes. This suggests that investing in nurse manager training could benefit both nurses and the healthcare system as a whole (Gunawan, et al., 2020). As a hospital manager or administrator, there are several responsibilities that contribute to the success of a hospital or healthcare facility. Maintaining retention among nursing staff is an important part of reducing costs, promoting consistent practices and maximizing the length of your nurses' employment. Understanding nurse retention and how to improve it may contribute to the success of an organization (Ung, et al., 2024). Definition of Nurses’ Retention Retention refers to an organization's ability to keep members of its staff employed. The number of nursess who resign or voluntarily leave their positions within a set amount of time to evaluate the level of retention within an organization. There are many factors that may contribute to an organization's retention rate, such as salary, benefits, workload, stress levels, leadership styles and company culture. A high retention rate, or low nurses turnover rate, is often a sign of a successful, positive and cohesive organization (Villamin, Lopez, Thapa, & Cleary, 2024). Nurses' retention refers to the ability of healthcare organizations to keep their nursing staff employed over time. It encompasses strategies and practices aimed at minimizing turnover rates and ensuring that nurses remain satisfied and engaged in their roles within the organization. High retention rates are indicative of a stable workforce, which is essential for maintaining continuity of care, enhancing patient outcomes, and reducing the costs associated with recruiting and training new staff. Effective retention strategies focus on creating a supportive work environment that meets the needs of nurses and fosters their professional growth (Alqahtani, Alenazi, & Alanazi, 2024). The importance of nurse retention There are several reasons retention is an important part of a successful workplace. In healthcare professions such as nursing, retention may be important in ensuring the success of a hospital or facility by: (Felder, Kuijper, Allen, Bal, & Wallenburg, 2024). Reducing costs Filling open positions can be a costly and time-consuming endeavor. Hospitals and healthcare facilities may spend important time and resources advertising open positions, recruiting candidates, reviewing applications and conducting interviews. The lower the retention rate, the more frequently HR department may need to employ these efforts. Improving nurse retention may help save valuable resources by reducing hospital's need to recruit new members of the nursing staff (Ung, et al., 2024). Maximizing length of employment: Improving nurse retention may help maximize the length of nurses' employment. Long-term relationships with nurses can often foster beneficial workplace dynamics, improve collaboration and promote a positive workplace culture. Long-term relationships with nursing staff may also help communicate more effectively and improve the success of the interactions (Lee, 2024). Promoting consistent practices : In order for practices to remain consistent, it's important that members of the nursing staff remain employed long enough to develop standard procedures and educate new nurses on their methods. If nurse retention is poor, the chances of a nursing staff developing these standards may decrease. Standardized practices with consistent techniques and care protocols are an important part of providing optimal treatment to patients, improving ease of communication and aligning expectations within your organization. Improved nurse retention may help to ensure consistency of healthcare protocols (Belaro, et al., 2024). Boosting staff morale : When members of nursing staff have the opportunity to form positive, fulfilling relationships, it may contribute to their morale in the workplace. Nursing can sometimes be a stressful and high-pressure career, so fostering supportive relationships within nursing staff is an important part of ensuring their well-being at work. Improved nurse retention may allow these important relationships to develop and could contribute to the happiness and success of the nursing team (Pressley, & Garside, 2023). Principles of Nurses’ Retention The principles of Nurses’ retention revolve around understanding the factors that contribute to job satisfaction and commitment among nursing staff. Key principles include nurses engagement, professional development, work-life balance, and recognition and rewards. Engaging nurses in decision-making processes and fostering a sense of ownership in their roles can significantly enhance retention. When nurses

feel valued and heard, they are more likely to remain committed to their organization. Providing opportunities for continuous education, mentorship, and career advancement is crucial for retaining nursing staff (Cardiff, Gershuni, & Giesbergen‐Brekelmans, 2023). Supporting nurses in achieving a healthy work-life balance is essential for preventing burnout and job dissatisfaction. Flexible scheduling, adequate staffing levels, and resources for managing workload can help nurses maintain this balance. Acknowledging the contributions of nursing staff through recognition programs and incentives fosters a positive work environment. When nurses feel appreciated for their efforts, they are more likely to stay with the organization (Alanazi, et al., 2023, December). Factors Affecting Nurses’ Retention Several factors influence nurse retention, including work environment, leadership support, job satisfaction, compensation and benefits, and personal factors. A positive organizational culture that promotes teamwork, open communication, and respect among colleagues are crucial for retaining nursing staff. Conversely, a toxic work environment can lead to high turnover rates. Effective leadership plays a significant role in nurse retention. Nurse managers who provide support, guidance, and mentorship create an environment where nurses feel valued and motivated to stay (Sommer, Wilhelm, & Wahl, 2024). Factors such as workload, autonomy, and opportunities for professional growth directly impact job satisfaction levels among nurses. High job satisfaction is linked to increased retention rates. Competitive salaries and comprehensive benefits packages are essential for attracting and retaining nursing staff. Organizations that offer fair compensation are more likely to retain experienced nurses. Individual circumstances, such as family commitments or personal health issues, can also influence a nurse's decision to stay or leave their position (Goyal, & Kaur, 2023).

Fig 2: , E., Dyson, J., Loke, J., & McKeown, E. (2020). Factors influencing the recruitment and retention of registered nurses in adult community nursing services: an integrative literature review. Primary health care research & development, 21, e31.‏ Consequences of Poor Retention The consequences of poor Nurses’ retention can be significant for healthcare organizations including increased turnover costs impact on patient care, decreased morale. High turnover rates lead to increased recruitment and training costs for organizations. The financial burden of replacing experienced nurses can strain budgets and resources. Frequent turnover disrupts continuity of care, which can negatively affect patient outcomes. Patients benefit from having consistent caregivers who understand their needs and preferences. High turnover can lead to decreased morale among remaining staff members who may feel overworked or unsupported as they pick up the slack for departing colleagues. Experienced nurses possess valuable knowledge about organizational practices and patient care protocols. Their departure can result in a loss of expertise that is difficult to replace (Goyal, & Kaur, 2023). Reasons for Challenges in Retention Several challenges complicate efforts to retain nursing staff such as workload pressures, changing workforce demographics, economic factors, and external competition. Increasing patient acuity levels and staffing shortages place significant demands on nurses, leading to burnout and job dissatisfaction, the nursing workforce is becoming increasingly diverse, with varying expectations regarding work-life balance, career advancement opportunities, and workplace culture (Udod, 2023). Budget constraints faced by healthcare organizations can limit resources available for retention initiatives such as professional development programs or competitive compensation packages. The healthcare industry is highly competitive, with multiple organizations vying for skilled nursing talent. This competition can drive up turnover rates if organizations do not effectively address the needs of their nursing staff (Liu, et al., 2023). How to Maintain Nurses Retention To maintain high levels of nurse retention, healthcare organizations can implement several strategies ( Fg3) including foster a positive work environment, invest in professional development, implement recognition programs, promote work-life balance, conduct regular surveys, and enhance leadership training. Creating a supportive culture that values teamwork, respect, and open communication encourages nurses to remain engaged in their roles (Silver, et al., 2024).

Fig 3: A scoping review into nurse retention https://www.nursingtimes.net/leadership/what-keeps-nurses-in-nursing-a-scoping-review-into-nurse-retention-10-10-2022/ Providing ongoing education opportunities, mentorship programs, and clear career pathways helps nurses feel valued and supported in their professional growth, establishing formal recognition initiatives that acknowledge the hard work of nursing staff reinforces their value within the organization, offering flexible scheduling options or resources to help manage workload can significantly enhance job satisfaction among nursing staff, and gathering feedback from nursing staff through surveys or focus groups allows organizations to identify areas for improvement related to retention strategies, and equipping nurse managers with effective leadership skills ensures they can support their teams adequately while fostering an environment conducive to retention (Rose, Skaczkowski, & Gunn, 2023). Effective nurse retention strategies are essential for maintaining a stable and satisfied nursing workforce, which directly impacts patient care quality and organizational performance. By focusing on these key areas, healthcare organizations can enhance job satisfaction among nursing staff, reduce turnover rates, and ultimately improve patient care quality. Implementing these principles requires a commitment from leadership to prioritize the needs of nurses and continuously assess and adapt retention strategies to meet the evolving demands of the healthcare landscape. The main principles guiding these strategies can be categorized into several key areas: (Adatara, et al., 2023). Creating a positive work environment: A positive work environment is foundational for nurse retention. This principle emphasizes the importance of fostering a culture that promotes collaboration, respect, and support among staff. Research indicates that when nurses feel valued and supported by their colleagues and leadership, job satisfaction increases, which in turn reduces turnover rates. A healthy work environment includes elements such as skilled communication, effective decision-making, appropriate staffing levels, and meaningful recognition of nurses' contributions. Organizations should regularly assess the health of their work environment to identify areas for improvement and implement changes that enhance nurses morale (Smama’h, et al., 2023). Supporting professional development : Investing in the professional growth of nursing staff is another critical principle for effective retention strategies. Providing opportunities for continuing education, mentorship programs, and clear career advancement pathways helps nurses feel empowered and engaged in their careers. Organizations that prioritize professional development demonstrate a commitment to their nursess' long-term success and satisfaction. This principle not only enhances individual competencies but also fosters a culture of continuous improvement within the organization. By encouraging nurses to pursue further education and skill enhancement, healthcare facilities can retain experienced staff who are equipped to provide high-quality care (Chang, & Cho, 2023).‏ Promoting work-life balance: Work-life balance is vital for preventing burnout and ensuring job satisfaction among nurses. Effective retention strategies should include flexible scheduling options, adequate staffing levels, and resources that help nurses manage their workload while maintaining personal commitments. Acknowledging the importance of work-life balance demonstrates an organization's understanding of the challenges faced by nursing professionals. By creating policies that support flexibility and well-being, healthcare organizations can foster a more satisfied workforce that is less likely to seek employment elsewhere (Bharath, 2023). Quality Of Care Quality of nursing care is a multifaceted concept that encompasses various dimensions essential for delivering effective and safe healthcare. It is defined as the degree to which nursing services enhance the likelihood of positive health outcomes for patients while aligning with evolving nursing knowledge and evidence-based practices. The American Nurses Association (ANA) emphasizes that quality nursing care involves not only the implementation of safe and effective interventions but also the consistency of these services with current best practices. This definition highlights the importance of integrating clinical competence, patient-centered approaches, and continuous improvement in nursing practices to achieve optimal patient outcomes (Casanova-Vivas, et al., 2023). Several attributes characterize high-quality nursing care. Key elements include nurse competency, effective communication, patient safety, and a supportive work environment. Competent nurses are essential for meeting patients' needs and ensuring that care is delivered effectively. Additionally, good communication between nurses, patients, and other healthcare professionals fosters collaboration and enhances the overall quality of care. The physical environment in which care is provided also plays a critical role; a well-equipped and safe setting contributes to better patient outcomes. (Berdida, 2024). Furthermore, leadership within nursing teams is crucial in establishing a culture that prioritizes quality care, encouraging staff engagement and adherence to best practices. The consequences of quality nursing care extend beyond individual patient outcomes; they also impact healthcare organizations and systems as a whole. High-quality nursing care leads to increased patient satisfaction, improved safety metrics, and reduced hospital readmission rates. Conversely, poor quality of care can result in negative patient experiences, increased healthcare costs due to complications or prolonged hospital stays, and higher turnover rates among nursing staff (Labrague, 2024). Therefore, it is imperative for healthcare organizations to continuously monitor and evaluate the quality of nursing care through various metrics and feedback mechanisms, ensuring that they meet established standards while striving for excellence in all aspects of patient care. By fostering an environment that supports quality improvement initiatives, healthcare organizations can enhance both nurse satisfaction and patient outcomes, ultimately leading to a more effective healthcare system. (Fatmawati, et al 2024). The World Health Organization (WHO) states that quality healthcare must be rendered to individuals and society (WHO 2024). Caring expressed in nursing is the intended and actual presence of the nurse who is recognized as a person who is loving, caring and growing in caring. Caring involves tending to the patient’s needs, providing physical and spiritual well-being, and building trust (Gonbaki, et al., 2024). Quality nursing care is viewed differently by healthcare professionals and patients. Therefore, competent nursing care is considered quality nursing care by healthcare professionals. Good interpersonal relationships and caring are perceived as quality nursing care. Nursing relationships with patients have been seen as a major therapeutic interpersonal process that cooperates with other human processes to enable individuals and communities to be healthy. This indicates that the nurse–patient relationship ensures that a patient’s needs are attended to as the patient will be free to voice their concerns, and it reduces the days of hospital stay and improves the quality of life. Relationships with family members make it possible to render quality care. (Kotronoulas, et al., 2024). Quality of nursing care can be defined as the degree to which nursing services enhance the likelihood of positive health outcomes for patients while aligning with current evidence-based practices. According to the American Nurses Association (ANA), quality nursing care increases the likelihood of desirable outcomes and is consistent with evolving nursing knowledge. This definition emphasizes three critical aspects: the effectiveness of nursing interventions, the achievement of positive patient outcomes, and adherence to evidence-based practices. Furthermore, quality care encompasses holistic approaches that address all patient needs, ensuring that care is not only competent but also compassionate and individualized (Abdollahi, 2024). Evolution of Quality Management The evolution of quality management has undergone significant transformations over the centuries, adapting to changing industrial landscapes and societal demands. The journey from early craftsmanship to modern quality management systems reflects the ongoing pursuit of excellence and continuous improvement within organizations. (De Giovanni, 2024). Statistical quality control: a new approach In the early 20th century, the introduction of statistical quality control revolutionized how organizations approached quality management. Dr. Walter Shewhart's work laid the foundation for using statistical methods to analyze and control variation in manufacturing processes. This marked a shift from reactive inspection to a more systematic approach to managing quality (Alzoubi, In'airat, & Ahmed, 2022). The quality movement: Deming and Juran The post-World War II era saw influential figures like Dr. W. Edwards Deming and Joseph Juran championing quality management principles. Deming emphasized statistical process control and continuous improvement, significantly impacting Japanese industries during their economic recovery. Juran introduced the "quality trilogy," focusing on quality planning, control, and improvement, further shaping modern quality management practices (Alzoubi, In'airat, & Ahmed, 2022). Total quality management (TQM): a paradigm shift Total Quality Management (TQM) emerged in the mid-20th century as a comprehensive approach emphasizing the involvement of all nurses in the pursuit of quality. TQM aimed to create a culture of quality throughout organizations by integrating principles into every aspect of operations. This shift marked a move away from isolated quality control efforts toward a holistic approach that included all nurses in the process (Alzoubi, In'airat, & Ahmed, 2022). The ISO 9000 Series: Standardization of Quality Management In the late 20th century, the International Organization for Standardization (ISO) developed the ISO 9000 series of quality management standards. These standards provided organizations with a framework for establishing and maintaining effective quality management systems. Adhering to ISO 9000 standards demonstrated a commitment to delivering quality products and services while meeting customer requirements (Kaur, et al., 2021). Emergence of six sigma In the 1980s, Motorola introduced Six Sigma as a methodology aimed at improving processes and eliminating defects. By utilizing quantitative tools such as control charts and process mapping, Six Sigma enabled organizations to enhance efficiency and reduce variability in their operations. This approach has since been widely adopted across various industries as a means of achieving higher levels of quality (Kaur, et al., 2021). Malcolm Baldrige national quality award Established in 1987, the Malcolm Baldrige National Quality Award recognizes organizations in the United States that demonstrate excellence in quality management practices. This award encourages organizations to strive for continuous improvement and performance excellence across all areas of their operations, reinforcing the importance of organizational commitment to quality (Kaur, Jet al., 2021). Continuous improvement and customer focus Central to the evolution of quality management is the concept of continuous improvement. Organizations are continually seeking ways to enhance their processes, products, and services to meet customers' ever-changing needs and expectations. Customer satisfaction has become a key focus as organizations recognize its importance in maintaining competitiveness in today's marketplace (Alzoubi, In'airat, & Ahmed, 2022). Importance of Quality of Nursing Care The importance of quality nursing care cannot be overstated. High-quality nursing care leads to improved patient outcomes, increased patient satisfaction, and reduced healthcare costs associated with complications or readmissions. When nurses provide quality care, they contribute to a positive healthcare environment that fosters trust and collaboration between patients and healthcare providers. Moreover, quality nursing care enhances the overall reputation of healthcare organizations, making them more attractive to potential patients and skilled professionals alike. Ultimately, prioritizing quality in nursing practice is essential for achieving optimal health outcomes and ensuring the sustainability of healthcare systems (Goodair, & Reeves, 2024). Fig 4: Saraswathula, A., Merck, S. J., Bai, G., Weston, C. M., Skinner, E. A., Taylor, A., ... & Berry, S. A. (2023). The volume and cost of quality metric reporting. Jama, 329(21), 1840-1847.‏ Principles of Quality of Nursing Care The main principles that define high-quality nursing care include holistic care, patient-centeredness, evidence-based practice, effective communication, and a commitment to safety and quality improvement. These principles work synergistically to enhance patient outcomes and satisfaction while promoting a positive work environment for nurses. By adhering to these principles, healthcare organizations can ensure that they provide comprehensive, compassionate, and effective nursing care that meets the diverse needs of their patients (van der Linde, et al., 2024). Several principles underpin effective quality nursing care. First, patient-centeredness is paramount; care should be tailored to meet individual patient needs, preferences, and values. Second, evidence-based practice is crucial for ensuring that nursing interventions are grounded in the latest research and clinical guidelines. Third, collaboration among interdisciplinary teams enhances the quality of care by leveraging diverse expertise to address complex patient needs. Fourth, continuous quality improvement emphasizes the need for ongoing assessment and refinement of nursing practices to enhance care delivery continually. Lastly, accountability ensures that nurses take responsibility for their actions and decisions in providing care. (Boussina, et al., 2024). Main Principles That Define High-Quality Nursing Care Holistic Care One of the primary principles defining high-quality nursing care is the provision of holistic care. This approach emphasizes the importance of addressing all aspects of a patient's well-being, including physical, emotional, social, and spiritual needs. Holistic care involves understanding each patient as a unique individual and tailoring interventions to meet their specific requirements. This principle ensures that nurses not only focus on treating medical conditions but also consider the broader context of a patient's life, which can significantly influence their health outcomes. By adopting a holistic perspective, nurses can foster stronger therapeutic relationships with patients, ultimately leading to improved satisfaction and better overall care (Bruyneel, et al., 2024). Patient-Centered Care Another essential principle of high-quality nursing care is patient-centeredness. This principle prioritizes the preferences, needs, and values of patients in all aspects of care delivery. Patient-centered care involves actively involving patients in decision-making processes regarding their treatment options and respecting their autonomy. Nurses play a crucial role in facilitating informed choices by providing comprehensive information about available interventions while considering patients' cultural backgrounds and personal beliefs. When patients feel empowered to participate in their care, they are more likely to adhere to treatment plans, leading to enhanced health outcomes and increased satisfaction with the healthcare experience (Labrague, 2024). Evidence-Based Practice The integration of evidence-based practice (EBP) is a fundamental principle that underpins high-quality nursing care. EBP involves utilizing the best available research evidence, clinical expertise, and patient values to guide nursing interventions and decision-making. By staying informed about the latest research findings and clinical guidelines, nurses can ensure that their practices are grounded in proven methodologies that enhance patient safety and effectiveness. This principle not only improves the quality of care provided but also fosters a culture of continuous learning and improvement within nursing teams. By embracing EBP, nurses can adapt to the evolving healthcare landscape and provide care that meets contemporary standards. (Zettl, Frahm, & Hecker, 2024).

Effective Communication Effective communication is another critical principle of high-quality nursing care. Clear and open communication among healthcare providers, patients, and families is essential for ensuring that all parties are informed and engaged in the care process. Nurses must possess strong communication skills to convey complex medical information in an understandable manner while also being attentive listeners. Good communication fosters trust between nurses and patients, enabling patients to express their concerns and preferences openly. Furthermore, effective interdisciplinary communication enhances collaboration among healthcare team members, ensuring coordinated efforts toward achieving optimal patient outcomes (Hoffmann, et al., (2024). Safety and Quality Improvement The principles of safety and continuous quality improvement are integral to high-quality nursing care. Ensuring patient safety involves implementing protocols that minimize risks associated with medical errors or adverse events. Nurses are at the forefront of monitoring patient conditions and identifying potential safety concerns before they escalate into serious issues. Additionally, engaging in quality improvement initiatives allows nursing teams to evaluate their practices critically and identify areas for enhancement. By fostering a culture that prioritizes safety and embraces feedback for improvement, healthcare organizations can create an environment where high-quality nursing care thrives (Pecoraro, et al., 2024).

Factors Affecting Quality of Nursing Care Several factors influence the quality of nursing care delivered in healthcare settings. Staffing levels play a significant role; inadequate staffing can lead to increased workloads for nurses, resulting in burnout and diminished care quality. Nurse education and training are also critical; well-educated nurses equipped with up-to-date knowledge are better positioned to provide high-quality care. Additionally, organizational culture impacts how nurses perceive their roles and responsibilities; a culture that promotes teamwork, communication, and support fosters an environment conducive to high-quality care. Finally, resource availability, including access to equipment and technology, directly affects nurses' ability to deliver effective interventions (Morris, Maliqi, Lattof, Strong, & Yaqub, 2024). Consequences of Poor-Quality Nursing Care The consequences of poor-quality nursing care can be severe for both patients and healthcare organizations. For patients, inadequate care can lead to adverse outcomes such as complications, prolonged hospital stays, and increased mortality rates. Poor-quality care also negatively affects patient satisfaction levels, leading to distrust in healthcare providers and reluctance to seek necessary medical attention in the future. For healthcare organizations, high turnover rates among nursing staff due to job dissatisfaction can result in increased recruitment costs and a loss of institutional knowledge. Furthermore, organizations may face reputational damage and financial penalties associated with poor patient outcomes (Same, et al., 2024).

Challenges in Maintaining Quality Nursing Care Several challenges hinder the maintenance of quality nursing care within healthcare settings. One significant challenge is staff shortages, which can lead to increased workloads for existing staff and a decline in morale. Additionally, rapid changes in healthcare technology require continuous training for nurses to ensure they are proficient in using new tools effectively. Regulatory pressures also pose challenges; compliance with various standards can be overwhelming for nursing staff already facing high demands. Furthermore, budget constraints may limit resources available for professional development or adequate staffing levels, impacting overall care quality. (Lacaille, et al., 2024).

Fig 5: Barriers on nursing care quality. HCP, healthcare professional . Kannappan, S. R., Veigas, J., & Walton, M. (2023). Patient Satisfaction and Barriers to Nursing Care Quality in Oncology Units. Journal of Health and Allied Sciences NU, 13(02), 247-252.‏https://www.researchgate.net/publication/363694611_Patient_Satisfaction_and_Barriers_to_Nursing_Care_Quality_in_Oncology_Units How to Maintain Quality Nursing Care To maintain high-quality nursing care, healthcare organizations should implement several strategies. First, investing in ongoing education and training ensures that nurses remain knowledgeable about best practices and emerging trends in healthcare. Second, fostering a supportive work environment that encourages open communication and collaboration among staff enhances teamwork and accountability. Third, organizations should prioritize adequate staffing levels to prevent burnout and ensure that nurses can provide attentive care without feeling overwhelmed. Additionally, implementing robust quality improvement initiatives allows organizations to assess their performance regularly and identify areas for enhancement. Finally, recognizing and rewarding nurses' contributions through formal recognition programs can boost morale and reinforce a commitment to delivering high-quality care. (Liu, et al., 2023). In summary, the quality of nursing care is a critical component of effective healthcare delivery that significantly influences patient outcomes and satisfaction levels. By understanding different strategies for maintenance, healthcare organizations can create environments that prioritize high-quality nursing practice. Investing in these areas not only benefits individual patients but also strengthens the overall healthcare system by fostering a culture of excellence in nursing care delivery (Goodair, & Reeves, 2024). Quality measures tools To effectively implement quality management practices, various tools are utilized to measure and assess quality within organizations. Here are some commonly used qualities measurement tools as statistical process control (SPC), quality audits, balanced scorecard, root cause analysis, pareto analysis, fishbone diagram (Ishikawa), surveys and feedback mechanisms, benchmarking, quality improvement teams, and lean six sigma (Kiwanuka, et al., 2021). Statistical Process Control (SPC) involves using statistical methods to monitor and control processes, ensuring they operate at their full potential, Quality audits help assess compliance with established standards and identify areas needing improvement, Balanced scorecard as a strategic planning tool measures organizational performance across multiple perspectives, including financial, customer, internal processes, and learning/growth, Root cause analysis tool helps identify underlying causes of defects or problems within processes, enabling organizations to implement effective corrective actions (Ali & Johl, 2022). Pareto Analysis; Based on the Pareto Principle (80/20 rule), this tool helps prioritize issues by identifying which problems have the most significant impact on overall performance, fishbone diagram (Ishikawa) is a visual tool helps identify potential causes of problems by categorizing them into different categories (e.g., people, processes, materials), surveys and feedback mechanisms as gathering feedback from customers and nursess provides valuable insights into perceptions of quality and areas for improvement, benchmarking; comparing organizational performance against industry standards or best practices helps identify gaps and opportunities for enhancement, quality improvement teams as forming teams focused on specific improvement initiatives fosters collaboration and collective problem-solving within organizations, and lean six sigma as combining lean principles with Six Sigma methodologies enhances process efficiency while reducing variability and waste. (Rosa, et al., 2024). Method Study Design: Descriptive correlational design was utilized in the present study. This design is a study in which the researcher is primary interested in describing relationships among variables, without seeking to establish a causal connection will utilize to conduct this study (Seeram, 2019). Study Setting: This study was conducted at all inpatient departments of King Fahad Central Hospital, Jazan, Abu Arish, KSA, which affiliated to a Ministry of Health (MOH) which aims to boost productivity, performance quality and efficiency of health services in hospitals. It consists of various inpatient departments such as Which serve the residents of Jazan, in Kingdom Saudi Arabia through 500 beds capacity. King Fahd Central Hospital in Jazan is one of the largest hospitals in Jazan district and King Fahd Hospital is located in Abu Arish province in Jazan district next to a village belonging to Abu Arish province and King Fahd Central Hospital in Jazan comes as part of the series of hospitals King Fahd of the Ministry of Health in Saudi Arabia, King Fahd Central Hospital consists of a wide range of specialized medical departments, including: • Medical and surgical inpatient departments. • Intensive care units for adults, pediatrics, and neonates. • Emergency and reception departments. • Operating rooms equipped with the latest technologies. • Obstetrics and gynecology departments. • Oncology, nephrology, cardiology, and neurology departments. The hospital is considered a major referral center in the region for receiving critical and complex cases, and it contributes to: • Providing specialized and high-quality care for patients. • Supporting peripheral hospitals through patient referrals. • Contributing to national programs of the Ministry of Health such as infection control, quality of care improvement, and healthcare performance development. • Offering educational and training services for medical and nursing students as well as trainees in various medical specialties Participants A Convenient (n=109) was utilized which include all available staff nurses who providing direct nursing care in the above-mentioned settings and fulfilled the criteria of having at least one-year of experience of work and willing to participate in the study and purposive sample of patient who full filled the criteria of (read and write, adult, receives care from pre-determined units) during time of data collection. Sample size calculation: The sample size for studying the quality of care, based on data from literature (Warshawsky, et al., 2022‏), to calculate the sample size with precision/absolute error of 5% and type 1 error of 5%, sample size was calculated according to the following formula, where, p0 = proportion (incidence) of population, p1 = proportion (incidence) of study group, N = sample size for study group, α = probability of type I error (usually 0.05), β= probability of type II error (usually 0.2), z = critical Z value for a given α or β. Based on the formula, the total sample size required for the study is 202 patients.

Tools of data collection: Three tools were used for data collection, namely First-Line Nurse Managers' Managerial Competency Scale, Nurses’ Retention Scale, and The Karen-patient Instrument. Tool I: First-Line Nurse Managers' Managerial Competency Scale: It is consisting of two parts: - First part: Personnel Characteristics of nurses as age, educational qualifications, years of experience and unit. Second part: First-Line Nurse Managers' Managerial Competency Scale This tool was developed by Gunawan, et al. (2019). Aimed to assess managerial competency of first-line nurse managers. It was measured by a 43-items consisted of seven dimensions which are leadership contains (14 items), facilitating spiritual nursing care contains (7items), self-management contains (6items), staffing and professional development contains (4items), utilizing informatics contains (4items), financial management contains (4items), and finally applying quality care improvement contains (4 items). Responses were measured on a five-point rating scale ranged from none of the time, once in a while, sometimes, quite often, always were scored respectively as 1, 2, 3, 4, and 5 The scoring system of First-Line Nurse Managers' Managerial Competency Scale was classified into three categories based on a predetermined cut-off *Correlation is significant at the 0.05 level (2-tailed).

Table (12): Shows correlation matrix between quality of care dimension and nurses' retention of the studied staff nurses. According to this table, there was a highly statistical significance positive relation between quality of care dimension and nurses' retention of the studied staff nurses.Discussion The managerial competency of first-line nurse managers plays a crucial role in both nurses’ retention and the quality of patient care. Competent nurse managers demonstrate strong leadership, effective communication, and the ability to create a supportive work environment (Mirzaei, et al., 2024). When first-line nurse managers possess essential managerial skills, such as conflict resolution, decision-making, and staff motivation, they foster a positive workplace culture where nurses feel valued, engaged, and supported. This, in turn, enhances job satisfaction, reduces burnout, and encourages nurses to remain in their positions rather than seeking employment elsewhere. A stable and well-supported nursing workforce leads to better patient care outcomes, as continuity of care is maintained, and experienced nurses can provide high-quality services without the disruptions caused by high turnover rates (Mirzaei, et al., 2024). So, the aim of the current study was to assess the managerial competency of first line nurse managers and its impact on nurses’ retention and quality of care at King Fahad Central Hospital. Regarding Managerial Competency of the first line nurse managers

According to the results of the present study, more than half of studied staff nurses had a high level of perception of managerial competency of first-line nurse managers. This result may be due to the healthcare organization invest in leadership training programs for nursing staff. This training equips nurses with the skills needed to understand and appreciate managerial roles, leading to managerial competency of first-line nurse managers. This finding consistent with Mirzaei, et al., (2024) who found that a significant proportion of staff nurses report a high level of perception regarding their head nurses' managerial competencies, highlighting the importance of effective leadership in nursing environments. This result one the same line with the results of a study done by El-sayed, Ahmed, & Zakaria, (2024) who found that all head nurses and staff nurses exhibited a high level of managerial proficiency, with over two-thirds of staff nurses expressing job satisfaction. As well as, this result is agreed with the study of Ali, & Khalifa, (2024) who studied that professional competency and moral courage among staff nurses‏, who indicated that more than three-fifths of the studied staff nurses reported a moderate level of professional managerial competency. Also, this study matched with Choi, Lee, Wong, & Tiu, (2022) who found that less than half of the respondents had a high level of perception of managerial competency. Likewise, a study was done by Lau, et al., (2014) who highlighted a general lack of awareness and clarity about professional competencies related to leadership and management. This result was disagree with a study was done by Alshamlani, et al., (2024) who found that the overall mean score indicating a low level of leadership competencies among nurse executives. The present findings indicated that less than half of studied nurses reported sometimes regarding facilitating spiritual nursing care dimension of managerial competency. This may be justified by heavy workloads and staffing shortages often make it difficult for nurses to prioritize spiritual care, as they focus on urgent medical tasks and patient safety, some healthcare facilities may not emphasize spiritual care in their policies or provide clear guidelines, leaving nurse managers uncertain about how to facilitate it effectively, as well as nurses may feel hesitant to engage spiritual care due to concerns about respecting diverse religious and cultural beliefs, fearing that they might unintentionally offend patients. This result agreed with Fadlilah et al., (2024); A systematic review on relationship between nurses' spiritual competence perceptions and profession, who indicated that spiritual competence is crucial for holistic patient care, yet many head nurses lack the necessary skills to provide effective spiritual care. Similarly in a multicenter study, only fewer nurses demonstrated high competence in spiritual care, while one fourth of them were classified as having low ability (Guo et al., 2023). Similarly, a study done by Guo, et al., (2024) who study the competence and perceptions of spiritual care among clinical nurses: A multicentre cross‐sectional study indicates that less than half of the studied nurses reported sometimes facilitating the spiritual nursing care dimension of managerial competency, highlighting a significant gap in their ability to provide essential spiritual care to patients. But in a study done by Soheili, & Mollai Iveli, (2019) who indicated that the concept of spirituality and spiritual care in nursing remains subjective and complex, suggesting that less than half of nurses may report facilitating spiritual care as part of their managerial competencies. The current findings indicate that about one third of studied nurses reported quite often regarding self-management dimension of managerial competency. This may be due to give the demanding nature of nursing, self-management skills like time management, emotional regulation, and adaptability become essential for coping with workplace challenges, motivating nurses to practice them frequently. This result similarly with a study was done by Kamel, Eid, & Ahmed, (2023) who found that the majority of first-line nurse managers had a poor perception level regarding self-management knowledge, and an inadequate perception level regarding self-management skills, indicating a significant gap in this managerial competency dimension. The study was done by Shaala, Shabaan, & EL-said, (2018) who found that nursing had weak levels in all dimensions of management competencies, including self-management. Pre-program assessments indicated that first line nurse managers had low levels in this area, highlighting a significant need for improvement in self-management competencies. The existent findings indicated that about one quarter of the studied nurses reported quite often and always regarding staffing and professional development dimension of managerial competency. On agreement with the results of the study done by Lee, Ahn, & Yu, (2024) who revealed that nursing managers identified "Allocation of appropriate nursing staff based on nursing requirements and adjustment of tasks" as a top-priority item, indicating a significant focus on staffing and professional development within managerial competency. The present findings indicated that about one third of studied nurses reported quite often regarding utilizing informatics dimension of managerial competency. This may be due to most healthcare facilities having adopted digital record-keeping systems, requiring nurses to frequently interact with informatics tools for patient documentation, medication administration, and care planning, and many healthcare institutions mandate the use of informatics systems for reporting patient data, monitoring vital signs, and managing workflows, making it a routine part of nursing practice. With the growing use of telehealth services, nurses are increasingly involved in managing virtual consultations, electronic patient monitoring, and digital communication with physicians and other healthcare professionals. On agreement with the results of the study done by Hussein, Al-Hamid, & Hassan, (2024) who found that only one fourth of nurse managers were proficient in total informatics competencies, indicating that many may not frequently utilize the informatics dimension of managerial competency in their decision-making processes. First-line nurse managers frequently report challenges regarding financial management competencies, which are essential for effective managerial roles in healthcare. The present findings indicated that more than half of studied nurses reported quite often regarding financial management dimension of managerial competency. This may be due to deficiency is compounded by insufficient financial management training within the nursing management curriculum, affecting their overall managerial effectiveness. This study harmony with Govender, & Mahomed, (2020) who revealed that nurse managers reported limited knowledge in financial management, indicating a gap in their competency. As well as the result in the line with a study done by Bayram, et al., (2022) who revealed that nineteen studies frequently addressed the concept of 'financial management competencies' among nurses manager, highlighting their significance in managerial roles. However, nurses often perceived moderate competencies or felt unprepared to manage budgets due to insufficient formal education and training. Also, the finding agree with study was done by McFarlan, (2020) who found that unit-based nurse managers' self-perception of business and financial competence was influenced by educational degree and participation in continuing education, indicating that many reported a lack of confidence in financial management despite its importance in their roles. Furthermore, study done by McFarlan, (2015) who indicate that nurse managers least competent in financial management knowledge and skills, highlighting this dimension as the most challenging to acquire, despite their clinical expertise and experience in nursing roles. As well as a study done by Brydges, Krepper, Nibert, Young, & Luquire, (2019) who ‏found that many executive nurse leaders reported weaknesses in financial literacy, indicating a significant gap in the financial management dimension of their managerial competency. This highlights the need for improved financial education and training in nursing leadership. The present findings indicated that more than half of studied nurses reported quite often regarding applying quality care improvement dimension of managerial competency. This can be attributed to the frequent application of quality care improvement among nurses reflects a healthcare system that prioritizes patient safety, efficiency, and excellence. Institutional policies, leadership support, training, and technology all play a role in ensuring that nurses consistently engage in activities that enhance care quality. This result congruence with the study done by Alzoubi, In'airat, & Ahmed, (2022)‏ who showed that manager nurses reported that they 'always' discuss decisions about care with nurses, indicating a strong application of the quality care improvement dimension of managerial competency, although weaknesses were noted in the political intervention and advisory dimension. In contrast the study done by Akkawi, Suleiman, & Alkaiyat, (2023), who found that nurses reported a high level of competence in questioning clinical practices to enhance quality care, with over two third rating themselves as competent in this area. And Wong, & Myers, (2015) who emphasized that nurse managers must incorporate evidence-based practice and technology into operational strategies to ensure quality patient care, highlighting the importance of evaluating and validating nursing competence in the context of quality outcomes. The present findings point out that the highest mean score was reported to leadership dimension as perceived by studied staff nurses, while the lowest mean score was regarded to staffing and professional development dimension of managerial competency. The findings indicated that staff nurses perceive leadership dimensions as the most significant aspect of managerial competency, while staffing and professional development rank lower. This perception underscores the importance of effective leadership in enhancing teamwork and resilience among nursing staff. The findings indicate that staff nurses perceived the leadership dimension of managerial competency more positively compared to the staffing and professional development dimension. This disparity may stem from the fact that leadership qualities, such as effective communication, decision-making, and support from nursing managers, are often more visible and acknowledged by staff. In contrast, staffing and professional development may be perceived as weaker areas if there are issues like inadequate staffing levels, limited opportunities for ongoing training, or insufficient support for skill enhancement. These factors can lead to lower perceptions of managerial competency in these specific domains, highlighting areas that need targeted improvements to foster a more balanced and supportive work environment for nurses. The result supported by Mohamed, Seada, & Ali, (2024) who indicated that staff nurses reported a high mean score for leadership behaviors, indicating that effective leadership fosters a supportive work environment. Leadership styles, particularly task-oriented approaches, were favored, suggesting that nurses value clear direction and support from their managers (Ünal, & Sütbaş, 2023). Similarly, the lowest scores were associated with staffing and professional development, highlighting a gap in perceived managerial competency in these areas (Elkhradly et al., 2024). A significant portion of nurse managers lacked formal training in leadership, which may contribute to inadequate staffing strategies and professional growth opportunities (Al-Nasri, 2024). This result agree with the study was done by Al-Nasri, (2024) who found that the highest mean score was leadership competency as reported by the staff nurses, while the lowest rank was associated with staffing and professional development dimensions, indicating areas needing further improvement in managerial competency among nurse managers. Similarly, a study done by Elkhradly, et al., (2024) who found that staff nurses perceived the highest mean score in the leadership dimension of head nurses' competencies, while the lowest rank was associated with the staffing and professional development dimension of managerial competency, indicating areas needing improvement. Part II: Nurses' retention of the studied staff nurses The results of the current study showed that the majority of studied staff nurses had a high level of nurses' retention. This may be due to the healthcare organization having strong management, supportive policies, and a positive work culture that meets the professional and personal needs of nurses, ultimately enhancing job satisfaction and long-term commitment. As well as flexible working hours, collegial support, and opportunities for professional development are essential for retention. Nurses emphasized the importance of constructive collaboration and supportive management. In the line with current results a study was done by Darwish, Ali, & Baraka, (2024) who found that the intent to stay among nurses was moderate at a high level. While this results disagreed with the study was done by Kumah, Nutakor, & Dorvlo, (2022) who found that more than half of nurses intended to leave their current facility, indicating a low level of retention perception despite a majority was a strongly agreeing that their managers exhibited a participatory management style, which is positively associated with retention. The present findings disagreed with a study done by Cathrine, (2019) who conducted a study on attrition analysis and retention strategies among staff nurses who indicated that a vast majority of nurses had a high attrition rate, suggesting that retention among staff nurses was low. Only the least of the nurses exhibited a moderate attrition rate, highlighting retention challenges. As well as, the study done by Naholi, Khayyat, Alandijani, Bafail, Bibera, & Aljedaani, (2023) who study the effectiveness of intervention strategies to improve nurse retention indicated the higher nursing retention rate, suggesting a significant improvement in nurse retention among the staff nurses at King Abdullah Medical Complex in Jeddah. In contrast, the study was done by Elhaddad, Safan, & Elshall, (2020) who revealed that the majority of nurses exhibited a low level of retention, indicating a need for improved perceptions. Part III: Quality of nursing care of the studied patients According to the results of the present study, the majority of studied patients had a high level of quality-of-care perception. This may be attributed to competent nursing care, effective communication, timely interventions, and a patient-centered approach. When healthcare providers focus on both medical and emotional needs, patients feel safe, valued, and satisfied with their care experience. This finding on the line with the results of the study done by Karim, Abdullah, Rahman, & Alam, (2016) who found that the overall level with the quality of care was high, indicating a high level of quality-of-care perception. Also the study done by Azeemi, et al., (2024) who found that a significant majority of patients expressed high satisfaction with various aspects of care, including physicians’ communication and treatment processes, indicating a high level of quality-of-care perception. In addition the study was done by Muthuram, & Dhakshinamoorthy, (2024), who reflecting positive perceptions of nursing care and the majority of patients had a high level of quality-of-care perception during their hospitalization experience. Likewise, the study done by Rane, (2024) who found that the majority of nurses held a neutral perception of quality patient care, with only the least expressing a positive perception. Thus, most studied nurses did not have a high level of quality-of-care perception. Instead, a study conducted on nurses, was done by Janghorban, et al., (2025) who found that the perceived quality of care among nurses was high, with an average score. This indicates that the majority of the nurses surveyed had a high level of quality-of-care perception. The present findings indicated that half of the studied patients reported strongly agree regarding the process quality dimension of quality of nursing care. The high level of patient agreement regarding the process quality dimension suggests that patients perceive the nursing care process as effective, thorough, and well-managed. This may be attributed to the nurses' adherence to established protocols, clear communication, and attentive patient interactions, which collectively enhance patients' confidence and satisfaction with the care they receive. Additionally, it reflects positively on the nurses’ competence and the healthcare facility's emphasis on maintaining high standards in the nursing care process, ultimately fostering a sense of trust and reassurance among patients during their treatment experience. This consensus is supported by various studies that assess patient perceptions of nursing care quality across different healthcare settings. Likewise, a study conducted in Gujarat, India, found that nursing care is a critical component of patient satisfaction, with patients expressing varying levels of satisfaction across different dimensions of care (Christi et al., 2024). Patients have reported a strong agreement regarding the process quality dimension of nursing care, highlighting its critical role in overall patient satisfaction. This dimension encompasses various factors, including effective communication, patient education, and the establishment of therapeutic relationships. The following sections elaborate on key aspects influencing this perception. The present findings indicated that half of studied patients reported strongly agree regarding process quality dimension of quality of nursing care. As well as a study done by Balouchi, Ebadi, Parvizy, & Nia, (2020) who indicated that patients perceived the process quality dimension of nursing care positively, highlighting aspects such as continuous monitoring of syndromes, effective patient education, efficient care, and strong therapeutic relationships, which contributed to their overall satisfaction with care received. The present findings indicated that less than half of studied patients reported strongly agree regarding the outcome quality dimension of quality of nursing care. Contradictory to the study done by Christi, Christian, Valand, & Gohil, (2024) who indicated that patients' expectations in some aspects of nursing care were not sufficiently met, suggesting that less than half of the patients may not have strongly agreed regarding the outcome quality dimension of nursing care quality. Additionally, Yusefi, et al., (2022) does not provide specific data indicating that less than half of the studied patients reported strongly agreeing regarding the outcome quality dimension of nursing care. It primarily discusses overall perceptions and dimensions of nursing service quality. The present findings point out that the highest mean score was reported to structure quality dimension of quality-of-care, while the lowest mean score was as regard process quality dimension of quality-of-care as perceived by studied patients. This can be attributed to various factors influencing patient perceptions, including individual values, socio-demographic variables, and the nature of care received. On agreement with Tarafder, (2024), who found that patients who reported the highest mean in the structure quality dimension of care, while the outcome quality dimension received the lowest rank. This reflects varying perceptions of care quality influenced by individual patient factors and experiences. Similarly, a study done by Schröder, Skårberg, & Lundqvist, (2021) who found that the patients' ratings of quality of care were generally high, with the highest rating for the structure dimension and the lowest for the structure dimension, indicating a disparity in perceived quality across different dimensions of care. Part IV: Relationship between managerial competency of first line nurse managers, nurses' retention and quality of care with personal characteristics The present results revealed that there was a highly statistically significant relationship between managerial competency and nurses' age, educational level and years of experience. The result in contrast with, a study done by Chin, et al., (2024), which does not report a highly statistically significant relationship between managerial competency and nurses' age, educational level, or years of experience. It focuses on the impact of leadership competencies, particularly conceptual skills, on managerial competencies among nurse managers. As well as the study found no significant correlation between age and nurses' competencies (p>0.05) while many nurses held master's degrees, the research did not establish a highly statistically significant relationship between managerial competency and age, educational level, or years of experience (Shurab, Ibrahim, Abdelaalem, Gabal, & Abdelhady, 2024). On contrast to a study done by Huynh, Huynh, & Dai Vo, (2024) who indicated that related factors with statistical significance include professional qualifications and time in charge of management, but it does not specifically mention a highly statistically significant relationship between managerial competency and nurses' age, educational level, or years of experience. As well as a study done by Mahdi, & Faraj, (2022) who indicated that there was no significant differences that were reported in leadership competencies concerning nurse managers' age, gender, qualification, and years of experience, indicating that managerial competency is not statistically significantly related to these factors among the studied nurse managers. The current results revealed that there was a highly statistically significant relationship between nurses' retention and their age, educational level and years of experience. The relationship between nurses' retention and factors such as age, educational level, and years of experience is highly statistically significant. Previous study indicated that younger nurses tend to have higher retention rates, as seen in studies where age was a critical predictor of retention willingness (Yang et al., 2023) (Muthiah et al., 2022). Additionally, educational attainment plays a vital role; nurses with advanced degrees, such as a master's, exhibit a greater intention to remain in their positions (Yang et al., 2023). Furthermore, years of experience significantly influence retention, with newer nurses showing a higher likelihood of staying compared to those with extensive experience (Chiao et al., 2021). One the same line with Lee, Yoon, & Ji, (2024) who found that new nurses' retention was significantly associated with younger age and higher readiness for practice, but it did not specifically address educational level or years of experience as influencing factors in retention. Similarly, a study done by Yang, Tseng, & Cheng, (2024) who identified a highly statistically significant relationship between nurses' retention willingness and their age, educational level, and years of experience. The present results revealed that there was a highly statistically significant relationship between patients' age and educational level and their perception of quality of care. Likewise, a study done by Tarafder, (2024) who found that patients' socio-demographic variables, particularly age and education level, significantly influence their perceived satisfaction with healthcare quality. Individual expectations and experiences shape these perceptions, highlighting the complexity of understanding patient satisfaction in relation to their demographic characteristics. On contrast a study was done by Bruyneel, et al., (2024) who found that there was no reported a highly statistically significant relationship between patients' age and educational level with their perception of quality of care. It focused on the type of procedure, nurses' gender, and waiting time as significant factors. Similarly, a study done by Zambujal, (2024) who found a statistically significant correlation between satisfaction and education level, indicating that participants with lower education levels reported higher perceived satisfaction. However, it did not specifically address the relationship between patients' age and their perception of quality of care. The study was done by Yusefi, et al., (2022) who found a positive relationship between patients' age and nursing service quality (r 0.536, P 0.03). However, there was no statistically significant relationship between patients' education level and their perception of nursing service quality. Part V: Correlation between managerial competency of first line nurse managers, nurses' retention and quality of care The present results revealed that there was a highly statistical significance positive correlation between total managerial competency and nurses' retention, but it does not specifically address the relationship between managerial competency and nurses' retention. The study was done by Hebashy Elewa, (2021) who found a highly positive statistically significant correlation between staff nurses' perception of nurse managers' leadership practices and their motivation and intention to leave, indicating that effective managerial competency may influence nurses' retention indirectly through motivation. Additionally, a study done by Numminen, Leino-Kilpi, Isoaho, & Meretoja, (2015) who indicated that while interpersonal skills of nurse managers significantly relate to anticipated turnover, it does not explicitly state a highly statistically significant positive relationship between total managerial competency and nurses' retention. Further research is recommended for clarity. As well as a study done by Smama’h, Eshah, Al-Oweidat, Rayan, & Nashwan, (2023) who conduct a study on the impact of leadership styles of nurse managers on nurses’ motivation and turnover intention among Jordanian nurses. And Soliman, El-Bialy, & El-liethey, (2020) who conduct a study on developing an instrument to assess the perceived job competencies of first-line nurse managers related to staff nurses’ performance and retention who found that there was a statistical significance relation between competencies of first-line nurse managers with their retention. Similarly, a study done by Chang, Yeh, Lai, & Yang, (2021) who conduct a study on job competency and intention to stay among nursing assistants: the mediating effects of intrinsic and extrinsic job satisfaction who found that there was a statistical significance relation between nurses competencies and intention to stay among nurses. Adding Choi, Lee, Wong, & Tiu, (2022) who conduct a study on competencies of nurse managers as predictors of staff nurses’ job satisfaction and turnover intention and found competencies of nurse managers considered one predictor of staff nurses’ job satisfaction and turnover intention. The current results revealed that there was a statistical significance positive correlation between total managerial competency and quality of care. On agreement with the results of a study done by Warshawsky, Cramer, Grandfield, & Schlotzhauer, (2022) who conduct a study on the influence of nurse manager competency on practice environment, missed nursing care, and patient care quality who found a high statistical significance positive correlation between head nurses' managerial competency and staff patient care quality. Additionally, a study done by Sroor, (2022) who conduct a study on the effect of managerial competencies on service quality field study on as well as Purwanto, & Anwar, (2019) who conduct a study on supervisors’ managerial competencies in function of management in improving the performance of implementer nurses’ in implementing nursing care who found the same results supervisors’ managerial competencies in improving patient quality of care. As well as a study done by Akhorshaideh, et al., (2023) who found a significant and positive association between quality management dimensions, including top management support, and the quality of healthcare services in Jordan, indicating that managerial competency positively influences the quality of care provided. The current results revealed that there was a highly statistical significance positive relation between quality-of-care dimension and nurses' retention of the studied staff nurses. On agreement with the results of Bruyneel, et al., (2024) who emphasize that quality nursing care is closely linked to staffing, including nurse retention. While it highlights the importance of safe staffing for quality patient care, it does not provide specific statistical significance regarding the relationship with nurse retention. This result in line with a study done by Elshahat, Shazly, & Abd-Elazeem, (2019) who found a highly positive statistically significant correlation between quality of work life dimensions, indicating that higher quality of care perceptions among staff nurses are associated with increased retention and lower turnover intentions. However this result in congruous with a study was done by Castle, Hyer, Harris, & Engberg, (2020) and Al Mutair, Al Mutairi, & Schwebius, (2021) who found low levels of nurse retention to be generally associated with poor performance on quality indicators, indicating a negative relationship rather than a positive one between quality-of-care dimensions and nurse retention among the studied staff.Conclusion Depending on the findings of the study, it was concluded that more than half of studied staff nurses, had high level of perception of managerial competency, as well as had high level nurses' retention whereas, had a high level of quality-of-care as perceived by patients. There was a highly statistical significance positive correlation between total managerial competency and nurses' retention, and a statistical significance positive correlation between total managerial competency and quality of care.

Recommendations Based on the study’s results the following recommendations were suggested: Recommendations for Nursing Managers: 1. Developing structured programs to strengthen nurse managers' competencies in leadership, communication, and team motivation to positively impact retention and quality of care. 2. Establishing reward systems, career progression pathways, and recognition initiatives to retain skilled nurses and reduce turnover. 3. Fostering a supportive work environment by encouraging participative decision-making and providing emotional and logistical support to staff to promote job satisfaction. 4. Promoting continuous quality improvement (CQI) by regularly assessing care quality indicators and encouraging nurses in quality initiatives to sustain high standards. 5. Encouraging open feedback channels by creating systems where nurses feel safe to voice concerns and provide suggestions regarding management and care practices. 6. Actively communicate with leadership by maintaining open and constructive communication with nurse managers to support collaborative improvements.

Recommendations to Staff Nurses: 1. Participating in professional development by engaging in training and workshops that improve both clinical and managerial skills. 2. Taking the initiative in applying evidence-based practices and reporting issues affecting patient care. 3. Sharing knowledge and skills with new nurses to build a cohesive and competent team. Recommendations for Future Research: 1. Evaluating how managerial competency and nurse retention influence patient satisfaction and outcomes. 2. Assess specific competency domains by studying which areas of managerial competency (e.g., conflict resolution, resource allocation) most significantly impact nurse retention. 3. Intervention-based studies by test the effectiveness of targeted interventions (like leadership training programs) on enhancing nurse retention and care quality.

Summary Managerial competence in nursing refers to the ability of nurse managers to effectively lead and manage nursing staff, ensure quality patient care, and facilitate organizational goals. This competence encompasses a range of skills, knowledge, and attributes that contribute to the successful functioning of healthcare teams and the overall healthcare environment. Various attributes of managerial competences as leadership skills, communication skills, clinical knowledge, organizational skills, emotional intelligence, critical thinking and problem-solving, and advocacy. Nurse retention is crucial in addressing high turnover rates in the healthcare sector. Key factors that influence retention include job satisfaction, organizational commitment, and effective recruitment strategies (Soliman, El-Bialy, & El-liethey, 2020). Improving these aspects can help reduce turnover and enhance employee morale. Nurse retention refers to the rate at which registered nurses stay employed by a healthcare organization over a given period of time. Addressing nurse turnover requires health care leaders to understand the factors contributing to it. This understanding can provide the insights needed to tackle the challenge head-on Aim of the study The aim of this study was to assess the managerial competency of first line nurse managers and its impact on nurses’ retention and quality of care at King Fahad Central Hospital Design The research design utilized was a descriptive correlational research design.

Tools of data collection: Three tools were used for data collection, namely First-Line Nurse Managers' Managerial Competency Scale, Nurses’ Retention Scale, and The Karen-patient Instrument. Tool I: First-Line Nurse Managers' Managerial Competency Scale: It is consisting of two parts: - First part: Personnel Characteristics of nurses as age, educational qualifications, years of experience and unit. Second part: First-Line Nurse Managers' Managerial Competency Scale This tool was developed by Gunawan, et al. (2019). Aimed to assess managerial competency of first-line nurse managers. It was measured by a 43-items consisted of seven dimensions which are leadership contains (14 items), facilitating spiritual nursing care contains (7items), self-management contains (6items), staffing and professional development contains (4items), utilizing informatics contains (4items), financial management contains (4items), and finally applying quality care improvement contains (4 items). A questionnaire was developed to collect data from the staff nurses. Responses were measured on a five-point rating scale ranged from none of the time, once in a while, sometimes, quite often, always were scored respectively as 1, 2, 3, 4, and 5 Tool (II): Nurses’ Retention Scale It was developed by Mueller & Mccloskey, (1990) to measure nurses’ intent to remain in their current job. Intent to stay at a job is determined based on the results of five items. Use 5-point Likert scale ranges from 1 (strongly disagree) to 5 (strongly agree). Tool (III): The Karen-patient Instrument. It consists of two parts: Part 1: This part included personal characteristics of patients such as age, education level, and marital status. Part II: It was developed by (Andersson ,1995). It is used to measure quality of nursing care from the point of patient view. It includes (35) items categories under three dimensions which are Structure quality (13) items, Process quality (10) items, Outcome quality (12) items used 5-point Likert scale ranges from 1 (strongly disagree) to 5 (strongly agree) Validity and reliability: Study tools were tested for their face and content validity by five experts in the field of the study, and accordingly the necessary modification was done. Reliability testing was done and judged by how the items that reflect the same construct yield similar results and will be tested for its reliability by using Cronbach alpha test. Cronbach’s alpha was applied to assess the internal consistency of the study tools, which needed to be at least 0.5 and preferably over 0.7. It was calculated for Tool I, Cronbach's alpha (0.859); Consequently, the rate of stability is (85.9 %), Tool II, Cronbach's alpha (0.849); Consequently, the rate of stability is (84.9 %), and Tool III Cronbach's alpha (0.869); Consequently, the rate of stability is (86.9 %) Pilot study A pilot study was carried out for 10% [10 nurses], and [20 patients] of the study participants to check and ensure the clarity and applicability of the tools in addition to calculating the duration required for filling all questionnaires. Ethical consideration: Ethical approval was obtained from the Research Ethical Committee of the Faculty of Nursing, Mansoura University (Ref:519). An agreement was obtained from the selected hospital for data collection. The verbal consent of staff nurses who meet the inclusion criteria to fill in the questionnaires and be part of the study was considered with written informed consent from participants. Data collection Data was collected from nurses and patients in the selected departments during their available shifts starting from 1st September 2024 till 30th December 2024. At the unit level, nurses were approached individually and after an explanation of the study purpose, nurses who agreed to participate in the study were given a voluntary written consent form to sign, after which the self-administered questionnaire was given to participant to complete. An official letter to carry out the study was issued from the faculty of Nursing, Mansoura University to the director of the King Fahad Central Hospital, Jazan, Abu Arish, KSA then an official written permission to carry out the study was obtained from the director of the King Fahad Central Hospital, Jazan, Abu Arish, KSA to obtain his approval to conduct the study after an explanation of the purpose of the study, data was collected from the nurses during their work shifts according to their accessible time. Data analysis The collected data was organized, tabulated, and statistically analyzed using SPSS software (Statistical Package for the Social Sciences, version 23, SPSS Inc. Chicago, IL, USA). Statistically significant was considered as (p-value < 0.01 & 0.05). Results: • More than half (51.4%) of studied staff nurses, had high level of perception of managerial competency of life whereas (48.6%) had moderate level of perception of managerial competency. • The majority (79.8%) of studied staff nurses, had high level of perception of nurses' retention whereas (20.2%) had moderate level of perception of nurses' retention. • The highest percentage (44.6%) of the studied patients strongly agreed as regards to the total quality-of-care, while the lowest percentage (4.5%) were strongly disagreed. • The total quality-of-care mean score was (152.14±12.32). The highest rank was as regard to structure quality dimension with mean score of (58.2±4.94) as perceived by studied patients, while the lowest rank was as regard outcome quality dimension with mean score of (50.73±5.4). • The majority (89.6%) of studied patients, had high level of quality of care perception whereas (10.4%) had moderate level of quality of care perception. • There was a highly statistical significance positive relation between total managerial competency and nurses' retention. • There was a statistical significance positive relation between total managerial competency and quality of care. • There was a highly statistical significance positive relation between total quality of care and the nurses' retention of the studied staff nurses. Conclusions, it was concluded that that more than half of studied staff nurses, had a high level of perception of managerial competency of life, had a high level of perception of nurses' retention whereas, had high level of quality-of-care perception. As well as that there was a highly statistical significance positive relation between total managerial competency and nurses' retention, and a statistical significance positive relation between total managerial competency and quality of care. Recommendations: Enhance managerial competency training by developing structured programs to strengthen nurse managers' competencies in leadership, communication, and team motivation to positively impact retention and quality of care.

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