Perceptions of managerial practice among Spanish nurse managers: a cross-sectional study using the E-EPTGE instrument

Abstract

Aim

To explore Spanish nurse managers’ perceptions of their professional activities using the validated Spanish version of the Nursing Managers’ Work Perception Scale (E-EPTGE).

Methods

A cross-sectional, descriptive-correlational study was conducted between December 2024 and April 2025. Using non-probabilistic snowball sampling, 140 nurse managers participated via an online survey promoted by national nursing organisations. The E-EPTGE (42 items, eight dimensions) measured the frequency of managerial activities on a 4-point Likert scale. Descriptive and non-parametric statistical analyses (Mann–Whitney, Kruskal–Wallis) were performed.

Results

The sample was predominantly female (81.4%), aged 41–50 (45.7%), with substantial nursing experience. The E-EPTGE showed excellent internal consistency (α = .961). Mean overall item score was 3.19, reflecting frequent engagement in managerial activities. Highest-rated dimensions included Professional, Ethical and Legal Practice (M = 3.54) and Planning and Organisation (M = 3.49). The lowest-rated was Political Intervention and Advisory (M = 2.70), suggesting reduced participation in institutional governance. Significant differences were found across age and experience groups (p < .05), indicating a positive correlation between maturity and perceived managerial competence.

Conclusions

Spanish nurse managers’ report strong involvement in ethical leadership and operational planning but show limited engagement in strategic roles. Enhancing leadership training and institutional inclusion is critical. The E-EPTGE demonstrates to be a robust tool for evaluating managerial competencies and informing evidence-based strategies for nursing leadership development.

Resumen

Objetivo

Explorar las percepciones de los gestores y supervisores de enfermería españoles sobre sus actividades profesionales, utilizando la versión validada en español de la Escala de Percepción del Trabajo del Gestor de Enfermería (E-EPTGE).

Métodos

Se realizó un estudio transversal, descriptivo-correlacional entre diciembre de 2024 y abril de 2025. Mediante un muestreo no probabilístico tipo bola de nieve. Participaron 140 gestores y supervisores de enfermería a través de una encuesta compartida en redes sociales. La E-EPTGE (42 ítems, ocho dimensiones) evaluó la realización y percepción de actividades de gestión en una escala Likert de 4 puntos. Se aplicaron análisis estadísticos descriptivos y no paramétricos (Mann–Whitney, Kruskal–Wallis).

Resultados

La muestra fue mayoritariamente femenina (81,4%), con edades entre 41 y 50 años (45,7%) y amplia experiencia profesional. La escala presentó una excelente consistencia interna (α = .961). La puntuación media global fue de 3.19, lo que indica una alta frecuencia y buena percepción de las actividades de gestión. Las dimensiones mejor valoradas fueron Práctica Profesional, Ética y Legal (M = 3.54) y Planificación y Organización (M = 3.49). La dimensión con menor puntuación fue Intervención Política y Asesoramiento (M = 2.70), sugiriendo escasa participación en las políticas institucionales. Se encontraron diferencias significativas según edad y experiencia (p < .05), indicando una correlación positiva entre experiencia profesional y percepción de competencia gestora.

Conclusiones

Los resultados indican un fuerte compromiso con el liderazgo ético y la planificación operativa, pero una baja implicación en funciones estratégicas institucionales. Siendo esencial reforzar la formación en liderazgo y su inclusión institucional. La E-EPTGE demostró ser una herramienta sólida para evaluar competencias gestoras e informar estrategias de desarrollo del liderazgo enfermero basadas en evidencia.

What is known?

• •

  Nurse managers are key to care quality, staff-coordination and organisational sustainability.

• •

  Strategic decision-making involvement in health systems remains limited.

• •

  Only few validated tools assess all management domains.

What it contribute?

• •

  Spanish nurse managers show strong ethical practice and team coordination engagement.

• •

  Age and managerial experience significantly influence self-perceived competence.

• •

  The reliable E-EPTGE provides adequate management activities assessment.

Introduction

Health organisations must rapidly respond to unprecedented challenges in a flexible and appropriate manner,¹ and across all dimensions, to ensure the achievement of institutional goals with the highest quality possible. In this context, nurse leaders and managers are key to governing and driving these challenges as they are able to improve patient safety outcomes, ensuring efficient work practices,^2,3 and caring staff, patients, and the healthcare institution itself.

In the current context, essential nursing leadership competencies include effective communication, the management of human and material resources, team motivation, conflict resolution, building resilience, and influencing strategic health decisions.^4,5 However, these competencies manifest differently depending on the managerial level. Unit-level leaders or supervisors are primarily responsible for the operational aspects of care, staff coordination, and ensuring the continuity of patient-centered care. In contrast, meso-level leaders or directors focus on strategic planning, organisational decision-making, and institutional representation.^6,7 Understanding this distinction is crucial for interpreting how nurse managers perceive their managerial activities in different healthcare settings.

They historically driven relevant changes and innovation, been at the frontline in health care major incidents,⁸ contributing to organisational success and upholding it over the long term.¹ They can impact positively professional health workforce and care institutions² and at the same time, have the reverse impact, as a result of poor job outcomes, dissatisfaction, high stress levels, and increased turnover.⁹

The presence of nurse managers remains limited in Spain, leading to a leadership deficit at various healthcare levels. According to the General Spanish Nursing Council, there are 345,969 nurses currently registered.¹⁰ The Spanish Association of Nurse Managers reported a total of 556 nurse managers, or in management positions affiliated in 2023,¹¹ and a recent national survey recognized over 90 nurses in strategic Spanish roles, including regional ministries, hospital management, and parliamentary positions.¹² Several factors contribute to this situation, including the limited institutional visibility of the role, insufficient professional recognition, and, most notably, inadequate education in management and leadership during undergraduate studies.^2,13

Objectively assessing their performance is crucial to enhance the care quality and improve specific health contexts, as they are responsible for coordinate teams, promote professional development, and participate in strategic decision making, directly influencing clinical outcomes, staff retention, and organisational climate.⁶

In this context, the present study aims to explore nurse managers’ perceptions of their professional activities to identify strengths and improvement management practice areas and to contribute to continuous improvement and evidence-based leadership.

Background

Nursing management has evolved from a focus on care oversight to a complex and comprehensive model that encompasses transformational leadership, quality management, professional development of the team, and participation in institutional policy making.⁶ In contemporary healthcare settings, the role of the nurse manager is critical to organisational sustainability and continuous improvement in patient care.⁷

The Spanish public management healthcare system emphasises efficiency, which indirectly promotes rotativity,¹⁴ and can negatively impact job satisfaction,¹⁵ and care quality. Recent studies suggest that Spanish nurse managers face important challenges related to their institutional recognition, limited involvement in strategic decisions and lack of continuous training adapted to their actual functions.^5,16 In this context, nursing leaders and managers resilience and influence are critical for the sustainability of units’ workforce and healthcare systems.²

Literature identifies key competencies, such as evidence-based decision-making, communication, motivation, conflict management, resource management, and the ability to influence public health policies^2,4,5 Assess nurse leaders’ capability and development of these competencies remains crucial for the overall continuous improvement of healthcare organisations.

The Spanish Competency Framework advocates for strengthening nursing leadership competencies,¹³ current literature consistently highlights the difficulty of evaluating them due to the lack of comprehensive and specific assessment tools.^17,18 Additionally, nursing students rarely aspire to managerial roles, partly due to the insufficient preparation in this area,² which undermines the development of a future nursing workforce equipped for leadership. This highlights the need to stimulate discussion around strengthening leadership and management education.^2,8

Only a limited number of validated instruments have been found in the literature. Filomeno et al., identified ten scales to measure nursing manager competencies at different hierarchical levels.⁴ Most of them only address specific areas such as transformational leadership, communication or organisational climate.⁴ Those tools present great conceptual heterogeneity, but no one himself explores all the intended areas, requiring the combination of various scales to reach a global perception of the managerial activities’ performance.

In response to this gap, Martins and Gonçalves, developed the Nursing Managers’ Work Perception Scale (EPTGE).¹⁸ The EPTGE, emerges as a solid and comprehensive tool, composed of 42 items distributed by eight key dimensions. This eight-dimensional structure covers essential aspects of management: Planning, organisation, management and control; Professional, ethical and legal practice; Quality and safety management; Professional development; Political intervention and advisory; Quality of care insurance; Practical training coordination and Nursing activities management.¹⁸

The instrument has revealed excellent internal reliability and structural validity,¹⁸ allowing the evaluation of the managerial activities from a broad and integrated perspective in different Portuguese contexts.^18,19 The EPTGE has been subsequently translated and validated previously for the Spanish reality currently in publication process. It was selected because it provides a comprehensive, integrated assessment of managerial practice, covering eight essential dimensions of nursing management, and the original version demonstrated robust psychometric properties.¹⁸ This comprehensive approach is useful for capturing the multifaceted nature of nursing leadership roles. Therefore, the present study intends to explore nursing managers’ perceptions of their professional activities through the application of the Spanish E-EPTGE scale.

Methods

Study design and setting

A descriptive-correlational, cross-sectional study was conducted to explore Spanish nurse managers’ perceptions of managerial activities, between December 2024 and April 2025. Ethical approval was granted by the local Spanish ethics committee (Ref. 041.10.2024). Informed consent was obtained from all participants following the Declaration of Helsinki. Participation was voluntary, anonymous, and confidential.

Participants and sampling

Considering the lack of official data published on how many of them really hold management positions, it is estimated that a low proportion of this group perform management functions and only a minority reach senior management positions, significantly reducing the universe of our sample.

To identify our sample strategically, a non-probabilistic snowball sampling process was conducted via social networks, in collaboration with the Spanish Association of Nurse Managers and the General Spanish Nursing Council. Organizations that disseminated and validated the scope of the research, ensuring that the targeted professionals were in management positions, through the inclusion of specific criteria (current role and years of management experience), ensuring the participants eligibility.

The survey hyperlink included a virtual Free and Informed Consent Form, a study description, and inclusion criteria (current nursing management/leadership role plus ≥1 year of management experience). Demographic characteristics (gender, age, educational level, years of professional nursing experience, years of management experience, setting of healthcare organisation, and current management role), and the Nursing Managers’ Job Perception Scale (EPTGE).

Measuring nurse perception of managerial activities

The EPTGE was developed by Martins & Gonçalves in 2021.¹⁸ The scale is organised into eight dimensions: Planning, organisation, management and control; Professional, ethical and legal practice; Quality and safety management; Professional development; Political intervention and advisory; Quality of care assurance; Practical training coordination; and Nursing activities management. Comprised of 42 items distributed across the dimensions, each item represented one individual nurse management activity. Each item was rated on a 4-point Likert scale (1 = never; 2 = sometimes; 3 = very often; 4 = always), producing total and subscale scores.¹⁸ The original instrument ensured a Cronbachs’ alpha of 0.950,¹⁸ and was translated, culturally adapted, and validated, retaining all items and dimensions of the original scale, according to international guidelines for Spanish reality in a previous study, currently in publication process.

Results

Sample and characterisation

A total of 140 nurse managers participated in this study. Considering the lack of official data defining the total number of nurse managers or supervisors in Spain and considering an estimate national figure below 2500 the present sample may represent a meaningful proportion of this target population. Additionally, although the E-EPTGE comprises 42 items, the sample size falls within the range commonly accepted for exploratory factor analysis (EFA). According to methodological literature, a subject-to-item ratio of 3:1 to 5:1 is considered acceptable, and samples between 100 and 200 participants are typically sufficient to produce stable factor solutions in descriptive and correlational research.^20,21

The sample was predominantly female (81.4%), with the majority aged between 41-50 years (45.7%). Most participants held a Masters’ degree (51.4%), followed by a Bachelors' (41.4%) and PhD (7.2%) degree. Regarding professional experience, 45.8% had between 21 and 30 years of nursing experience and 72.9% had up to 10 years of management experience. The majority worked in hospital settings (87.2%), with primary care (2.1%) and elderly care centres (1.4%) less represented. Current roles included Supervisor (55%), Manager (35%), and Director or Subdirector (8.6%). The complete sample characteristics can be appreciated in Table 1.

Table 1.

Sample characterisation.

Variables	N	%
Gender (N = 140)
Male	26	18.6%
Female	114	81.4%
Age Groups (N = 140)
20−30	8	5.7%
31−40	27	19.3%
41−50	64	45.7%
51−60	29	20.7%
<60	12	8.6%
Educational Level (N = 140)
Bachelors’ Degree	58	41.4%
Masters’ Degree	72	51.4%
PhD	10	7.2%
Years of professional experience (N = 140)
Up to 10 years	17	12.1%
Between 11–20 years	31	22.1%
Between 21–30 years	64	45.8%
More than 31 years	28	20%
Management Experience (N = 140)
Up to 10 years	102	72.9%
Between 11–20 years	29	20.7%
Between 21–30 years	7	5.0%
More than 31 years	2	1.4%
Work setting (N = 140)
Primary care	3	2.1%
Hospital	122	87.2%
Elderly care centre	2	1.4%
Other	13	9.3%
Current role (N = 140)
Supervisor	77	55%
Manager	49	35%
Sub Director	3	2.1%
Director	9	6.5%
University Collaborator/Professor	2	1.4%

Perception of managerial activities

Management activities performance was assessed with the EPTGE. The psychometric instrument demonstrated excellent internal consistency (α = .961) with item variances ranging from .293 to .962, suggesting good sensitivity. An average overall item means of 3.19, and individual dimensions means ranging from 2.70 to 3.54 was found, indicating high engagement in management activities.

Most respondents indicated they “always” or “very often” performed core management activities across all dimensions. The highest performing activities dimensions were “Professional, ethical and legal practice”, with more than 90% of managers reporting regularly respect patient and staff values (M = 3.54, SD = .541), safeguard patient privacy and individual respect (M = 3.48, SD = .605), and promotes clinical decision-making (M = 3.24, SD = .685). And “Planning organisation, management and control”, in which 94.3% of respondents reported frequently supervises care delivery (M = 2.89, SD = .750) and promotes team spirit and cohesion (M = 3.49, SD = .606).

Conversely, the “Political intervention and advisory” dimension showed the lowest activities engagement level, with 43,5% (n = 61) of respondents with less or no participation in institutional health policy definition and implementation (M = 2.70, SD = .862). Although slightly less frequent than other dimensions, strategic planning participation (78,5%, n = 110) and department project development (77,8%, n = 109) items were still predominantly rated as “very often” or “always” performed activities. See Table 2 for the overall EPTGE activities scores.

Table 2.

EPTGE activities scores.

			Never		Sometimes		Very often		Always
Dim	A*	As Manager/Leader you…	N°	%	N°	%	N°	%	N°	%
Planning, organisation, management and control	A1	Supervises the scheduled care delivery.	4	2.9	36	25.7	72	51.4	28	20.0
	A2	Develops continuous quality improvement plans.	1	0.7	26	18.6	81	57.9	32	22.9
	A3	Attends to the shift change.	17	12.1	37	26.4	49	35.0	37	26.4
	A4	Assesses nursing performance.	5	3.6	16	11.4	70	50.0	49	35.0
	A5	Creates, supports and develops cohesion, team spirit and the workplace atmosphere, managing conflicts.	0	0.0	8	5.7	56	40.0	76	54.3
	A6	Promotes team commitment and motivation (global vision).	2	1.4	2	1.4	63	45.0	73	52.1
	A7	Ensures planning, organisation, coordination and evaluation of quality support services.	4	2.9	12	8.6	76	54.3	48	34.3
	A8	Acts as multi- and intradisciplinary team trainer.	1	0.7	30	21.4	68	48.6	41	29.3
	A9	Promotes and assesses the nursing and other staff satisfaction.	4	2.9	25	17.9	78	55.7	33	23.6
	A10	Creates and preserves cooperative team working conditions.	2	1.4	12	8.6	68	48.6	58	41.4
Professional, ethical and legal practice	A11	Cares about nursing and patient values.	0	0.0	3	2.1	58	41.1	79	56.4
	A12	Discusses with the team ethical issues related to care.	1	0.7	16	11.4	79	56.4	44	31.4
	A13	Controls patient privacy and individuality respect.	0	0.0	8	5.7	57	40.7	75	53.6
	A14	Ensures legal conditions for care and professional practice.	0	0.0	8	5.7	61	43.6	71	50.7
	A15	Discusses care decisions with nursing staff.	2	1.4	15	10.7	84	60.0	39	27.9
	A16	Promotes clinical decision-making.	2	1.4	14	10.0	73	52.1	51	36.4
Quality and safety management	A17	Provides and guarantees necessary means and resources for the care provision.	1	0.7	4	2.9	76	54.3	59	42.1
	A18	Contributes to good practice development through the appropriate material resources of the unit use.	2	1.4	7	5.0	67	47.9	64	45.7
	A19	Ensures safe environments identifying and managing risks and introducing corrective actions.	1	0.7	7	5.0	70	50.0	62	44.3
	A20	Manages patients, families and team serious clinical situations.	7	5.0	22	15.7	60	42.9	51	36.4
	A21	Coordinates the staff recruitment and integration process while undertaking a referral role.	2	1.4	9	6.4	77	55.0	52	37.1
	A22	Makes decisions to ensure the best care for patients.	2	1.4	9	6.4	69	49.3	60	42.9
	A23	Tailors’ material resources to needs, considering cost-benefit ratio	0	0.0	17	12.1	65	46.4	58	41.4
Professional development	A24	Promotes evidence-based nursing.	1	0.7	21	15.0	53	37.9	65	46.4
	A25	Promotes formal and informal staff training.	2	1.4	7	5.0	63	45.0	68	48.6
	A26	Encourages nursing staff to self-train.	0	0.0	10	7.1	52	37.1	78	55.7
	A27	Provides practice reflection opportunities to promote staff commitment to their own skills management.	3	2.1	36	25.7	64	45.7	37	26.4
Political intervention and advisory	A28	Participates in Institutional health policy definition and implementation.	9	6.4	52	37.1	51	36.4	28	20.0
	A29	Participates in the units’ strategic planning.	4	2.9	26	18.6	73	52.1	37	26.4
	A30	Produces service reports	8	5.7	36	25.7	61	43.6	35	25.0
	A31	Develops and undertakes department projects, involving himself and the staff in those actions.	1	0.7	30	21.4	71	50.7	38	27.1
	A32	Participates in working groups and committees in the field of clinical and non-clinical risk management.	4	2.9	31	22.1	59	42.1	46	32.9
Quality of care insurance	A33	Analyses patient risks related to the care and unit conditions.	3	2.1	18	12.9	84	60.0	35	25.0
	A34	Ensures safe staffing in accordance with the professional quality standards.	4	2.9	11	7.9	79	56.4	46	32.9
	A35	Analyses and assesses the quality of care provided and implements corrective actions.	2	1.4	22	15.7	64	45.7	52	37.1
	A36	Develops, applies, evaluates and updates procedures to guide equipment and materials handling.	1	0.7	17	12.1	69	49.3	53	37.9
Practical training coordination	A37	Organises and promotes nursing meetings.	3	2.1	20	14.3	74	52.9	43	30.7
	A38	Provides guidance on the most complex care.	3	2.1	23	16.4	77	55.0	37	26.4
	A39	Ensures formal communication procedures between staff and other collaborators.	4	2.9	14	10.0	74	52.9	48	34.3
Nursing activities management	A40	Calculates required nursing workforce according to the service conditions.	3	2.1	11	7.6	55	39.3	71	50.7
	A41	Allocates and plans nursing according to care intensity and complexity, by pre-determined methods to anticipate the number of care hours required.	10	7.1	25	17.9	67	47.9	38	27.1
	A42	Allocates nurses according to patients' needs	6	4.3	19	13.6	58	41.4	57	40.7

Inferential Statistics (Mann–Whitney and Kruskal–Wallis tests) were applied to explore differences across demographic variables, and no statistically significant differences were found across gender, work setting, professional category, or managerial role. However, age group and years of management experience indicates statistically significant differences across several dimensions (p < .05). Regarding age group, all eight scale dimensions showed statistically significant variation across age categories, with the lowest p-values observed for "Nursing activities management" (p = .004) and "Practical training coordination" (p = .006).

Post-hoc pairwise comparisons conducted following the significant Kruskal-Wallis’ test revealed that nurse managers aged between 31 and 40 years had a significantly higher perception and engagement of the “nursing activities management” than those aged between 20 and 30 years (p < .05), as illustrated in Fig. 1. This may indicate that the perception of managerial competence evolves with increased professional maturity and leadership experience.

Figure 1.

Age group pairwise comparisons.

Discussion

Results reflect a strong commitment to management-related activities that are directly associated with advanced nursing leadership competencies. The data suggest that the EPTGE scale adequately captures the breadth of nurse managers’ responsibilities within complex healthcare environments. The high overall mean score (M = 3.19) and excellent internal consistency (α = .961) support its psychometric robustness, consistent with precedent findings.^18,19 These results also align with international bodies recommendations, which highlight the strengthening of nursing leadership as essential for improving care quality.^22,23

Findings also suggest that perceptions of management competence may evolve with age and experience. Statistically significant differences were found by age group and years of management experience (p < .05), indicating that professional maturity may enhance the self-perception of managerial competence. These findings are consistent with precedent studies, which highlight how managerial and practical experience enables more confident adoption of managerial roles and transformational leadership practices.^16,24

Conversely, no statistically significant differences were found by gender across the EPTGE dimensions. However, this finding is relevant in the broader debate on gender bias in nursing leadership. Previous literature has consistently identified the persistence of a “glass ceiling” that limits womens’ progression into strategic leadership roles, regardless of their professional competence or experience.²⁵

Regarding the scale dimensions, “Ethical and legal professional practice.” appears among the highest-rated dimensions, particularly “Shows concern for nursing and patient values” item revelling the highest mean score (M = 3.54; SD = .541). Highlighting a strong ethical orientation among nurse managers and a clear commitment to person-centred care. Finding supported by previous research, which demonstrates that ethical, transformational leadership positively influences team satisfaction and care quality.^6,7

“Encourages self-directed learning” item (M = 3.49; SD = .629) also received high ratings, underscoring the importance attributed to ongoing professional development within the nursing teams. This is consistent with the literature emphasizing that nursing managers must not only lead operationally but also inspire and mentor, promoting the acquisition of advanced competencies among staff.^4,26

Conversely, respondents demonstrate low commitment to some activities, as “Attends to the shift change” (M = 2.76; SD = .981). Activity representing an operational task, while still important, may be more frequently delegated in highly structured healthcare settings, suggesting reduced managers direct involvement. Which could negatively impact care continuity and personalised patient care, central to nursing leadership.^9,26 This finding raises an important discussion about how balance strategic and administrative functions with active participation in key clinical processes.

Another relevant finding was the lower engagement reported in strategic functions as “Participates in Institutional health policy definition and implementation” (M = 2.70; SD = .862) and “Produces service reports” (M = 2.88; SD = .852), suggesting limited involvement of nurse managers in institutional-level decision-making. This statement is consistent with findings from other international contexts, where nursing managers are underrepresented in strategic decision-making forums.²⁷ Limiting not only professional visibility but also reducing the potential influence of nursing perspectives on organisational governance and healthcare policy.²³

European studies, point to the persistent need to strengthen the visibility and participation of nurse leaders in healthcare governance.^5,27 However, the evidence of low political intervention highlights the need to strengthen strategic leadership training and institutional participation, consistent with the Strategic Framework for Nursing Care²⁸ In light of these results, continuous professional development, postgraduate education, and leadership training have emerged as fundamental strategies for reinforcing nurse manager profiles. Advanced academic qualifications have been associated with improved decision-making, better conflict resolution, and greater strategic involvement.^2,6,26 Encouraging academic progression and lifelong learning may therefore support more active participation in institutional processes and policy development.

Previous studies implementing the EPTGE found similar findings, specifically, a strong involvement in ethical practice, professional development and operational planning, while participation in institutional policy and political intervention remained limited.^18,19 Suggesting that reduced engagement in strategic and political activities may be a common challenge in southern European healthcare contexts where managerial roles tend to be more operationally focused.

The development of specific training programmes,²⁹ along with greater support from nursing schools, could enhance leadership preparation and promote active participation in institutional decision-making. This, in turn, would improve patient safety and team cohesion. At the managerial level, it would help position the profession within decision-making bodies, facilitating the integration of leadership skills into nursing undergraduate curricula, and allowing the EPTGE to be linked to organisational research outcomes, as suggested by Wong, Cummings, and Ducharme.³⁰ Additionally, addressing gender bias remains crucial, as the “glass ceiling” continues to limit nurses’ access to strategic leadership roles.

This study had some limitations that must be pointed. First, the use of snowball sampling through social media may have introduced a selection bias, potentially limiting the representativeness of the sample. Second, the cross-sectional design precludes the establishment of causal relationships between variables. Moreover, the use of a self-report instrument may be influenced by social desirability bias, particularly for items concerning ethical and institutional functions.

Further studies should explore the relationship between EPTGE scores and clinical or organisational outcomes and comparing perceptions between unit-level supervisors and meso-level managers, exploring different behavioral patterns and providing further insight into the applicability of the tool across different levels of managemen. Additionally, research should explore barriers limiting nurse managers’ involvement in strategic decision making and assess the impact of leadership training programmes on managerial performance.

Conclusion

The findings indicate strong commitment among nurse managers in key areas, such as ethical practice, team cohesion, and organisational planning, while also identifying areas for improvement, particularly in institutional policy involvement and reporting. Perceptions of managerial competence were positively associated with age and professional experience, suggesting that leadership confidence develops progressively throughout ones’ career and underscores the importance of ongoing professional development. These results highlight the dual challenge faced by nurse managers: maintaining operational and ethical excellence, while promoting their involvement in strategic decision-making processes.

The E-EPTGE demonstrated strong validity and reliability as a tool for assessing nursing management activities, identifying training needs, and guiding leadership and management improvement strategies. Its application supports evidence-based decision-making, enhances care quality, and strengthens the professional recognition and strategic positioning of nurse managers. Based on these findings, we recommend the promotion and integration of nurse leaders into institutional decision-making processes by Health Ministry. Additionally, healthcare management bodies should consider the implementation of structured mentoring initiatives, while professional nursing organisations are encouraged to develop leadership training programmes. Finally, nursing faculties should integrate management and leadership competencies into undergraduate and graduate curricula to better prepare future nurse leaders.

CRediT authorship contribution statement

C.E.: Resources, Conceptualization, Investigation, Methodology, Data curation, Formal analysis, Supervision, Validation, Writing - original draft, Writing - review & editing. P.S.G.: Conceptualization, Investigation, Methodology, Data curation, Writing - original draft. N.Q.F.: Conceptualization, Investigation, Methodology, Data curation, Writing - original draft. M.M.M.: Conceptualization, Methodology, Data curation, Software, Formal analysis, Supervision, Validation, Writing - review & editing.

Funding statement

Open access funding provided by Universidad de Salamanca.

Acknowledgments

Authors would like to acknowledge all participants for their voluntary involvement, and also thanks’ Fdz-Lasquetty Blanc, B., for kindly sharing the scale in his social networks.