In this section, we present our inductive findings of reported leadership skills under five inductively identified domains i) communication and relationship management, ii) stewardship; iii) professional development; iv) knowledge of the healthcare environment; and v) information technology and finance. Domains and leadership skills are referred to simply as ‘domains’ and ‘skills’ respectively to improve clarity. Participants were purposefully grouped into two categories to explore potential differences between the leadership skills described by study participants: i) with a health qualification (n = 13) and ii) without a health qualification (n = 6).
Communication and relationship management
‘Communication and relationship management’ skills included a leader’s ability to communicate clearly and concisely with internal and external stakeholders, share clinical and industry related knowledge and employ effective complaint management processes within the organisation. As part of the current study, relationship management and communication skills were strongly emphasized by most study participants, however skills including the ability to negotiate with externals stakeholders were less of a focus.
Participants who possessed a formal health qualification reported that a managers’ ability to build and nurture collaborative relationships with residents, staff and external providers was important to promoting the quality performance of an organisation.
“So when you are dealing with the various stakeholders, trying to be a bit more collaborative as opposed to directive. This can be an effective way to developing rapport and longstanding relationships” Clinical Care Coordinator, Regional Facility, ID4.
Among these health-qualified participants, a key theme was senior manager’s capacity to share knowledge and build working relationships with other RACFs. Participants describe how this helped designing and implementing processes that influenced the quality of RACF health care services. Of note, however, the importance of networking and collaboration with other organisations was not described by any of the senior managers who did not possess a formal health qualification.
“As organizations, big or small, we [senior managers] need to collaborate and share our knowledge. We do not do that very well. We do have a regional facility management group meeting, and we talk. We talk to things that could help with raising quality within our facilities” Clinical Operations Manager, Regional Facility, ID15.
As an important mechanism to developing positive RACF stakeholder relationships, almost all of the participants with a formal health qualification recommended that senior managers develop the skills to foster trust and rapport with residents and their families. The need for managers to effectively address resident complaints was strongly emphasised as a mechanism to ensure quality of care, as described by one participant:
“Your ability to manage complaints is important. It drives positive clinical care outcomes and it helps to you to effectively negotiate with service providers to come in to look after your community in a way that the community expects” Facility Manager, Regional Facility, ID7.
As a method to developing sustained relationships with staff, it was recommended that senior managers develop and employ effective interpersonal skills such as active listening techniques to enhance teamwork across all levels of the organisation. However, this leadership strategy was only emphasised by participants who were qualified health practitioners such as this CEO who possessed both formal nursing and business qualifications:
“The first thing that comes to mind is being able to listen. I think that is a key thing in terms of managing and caring for people. So I am opening to listening to people. I've certainly learned to be more patient and take in what is happening around me before making a decision that could impact the way that care is carried out” CEO, Regional Facility, ID1.
A manager’s ability to build and nurture collaborative relationships with residents, staff and external providers was emphasized by both health-qualified and non-health qualified participants as important to promoting the quality performance of an organisation. As one qualified health practitioner reported: .
“You have to understand people, relationships and what drives them. This helps you to pick up how you can get the best out of them. For the residents, you have to understand their story and what they need from you as the provider” Clinical Care Coordinator, Rural Facility, ID3.
‘Stewardship’ skills included the ability of senior managers to inspire organisational change and create a positive organisational culture that celebrates the diversity of staff and residents. Less emphasis was placed on skills including a managers’ ability to promote lifelong learning or provide the leadership of ethical health care services.
Senior managers from both participant categories recognised the importance of interpreting regulations that influence health service delivery within an organisation, particularly during a time of regulatory and legislative change. Of the qualified health practitioners that were interviewed, one CEO and one Facility Manager reported that the ability of all RAC senior managers to comprehend and monitor legal and regulatory standards is an essential leadership skill influencing quality of care.
“Above all, you need to be aware of and fully understand the frameworks and policies that dictate the way your organisation operates. Without this, you don’t know where to start when planning for quality compliance” Facility Manager, Regional Facility, ID22.
“Managers need to be familiar with the legislation or the accreditation, all of the regulatory compliance issues that go with this unique type of industry [residential aged care]” CEO, Regional Facility,ID2.
One Director of Nursing, strongly emphasised the importance of managers being able to interpret regulatory environments, and then educate staff and residents regarding quality compliance to ensure quality performance across the organisation.
“Another really important skill is being able to educate patient care team members and the resident on the legislative and regulatory processes and methods for influencing both during daily operations” Director of Nursing, Rural Facility,ID6.
Drawing attention to recent regulatory changes in Australia, including the introduction of the new Aged Care Quality Standard and Charter of Aged Care Rights in 2019, several participants reflected on the way senior managers needed to be able to serve as a “change agent” to assist staff and residents to understand reasons for change. Interestingly, however, descriptions regarding the influence of change management on quality of care were only reported by those who did not possess a formal health qualification.
“Sometimes there are people who have worked in this industry for 30 or 40 years and say this is the way they've always done it and they're not going to change, and so then your conversation has to be probably a bit more directive around, well, actually, it needs to change. You need to be a vessel to filter messages around change and make sure that actions follow” Facility Manager, Rural Facility, ID19.
To develop a comprehensive change management plan that positively influences RACF care quality, two participants reported that senior managers require the capacity to acknowledge obstacles to organisational change, including employee resistance. It was also reported by one Facility Manager that RAC senior managers should possess the ability to patiently observe the challenges to change management before employing the change process.
“So my advice to a new manager is just be very comfortable to listen, observe, sit back and understand, and get to know what you're actually dealing with. Without this insight, you will struggle to manage resistance to change” Facility Manager, Regional Faciliy,ID8.
As a strategy to minimise employee resistance, one Facility Manager with a tertiary Business qualification emphasised that a collaborative approach to decision-making processes was a successful method to empowering staff at all levels of the organisation to help embrace and champion change.
“I always aim to be motivating; a motivational leader that staff can follow and be inspired by, particularly when the message of change is on the table” Facility Manager, Regional Facility, ID18.
The ability of senior managers to develop and lead a positive organisational culture was reported across both participant categories as a contributing factor to quality of care. Linking positive organisational culture to high quality outcomes across the organization for example, on participant noted:
“Culture is critical, and something I always bang on about here is that you can walk into a workplace and within five minutes you can actually have a pretty good idea of what the quality of care would be like” Facility Manager, Regional Facility, ID7.
The same Facility Manager also reported that the RACF leadership team should possess the skills to define diversity within its organisation.
“So part of my role is I do some social profiling of our consumers and of our staff, trying to get to know who they are as a community. So I definitely do try and orientate them to the different cultures and what's important. It helps everyone to feel connected to each other” Facility Manager, Regional Facility, ID7.
‘Professional development’ skills included the ability of a senior manager to create working environments that promoted the accountability of internal and external services to the delivery of quality health care. Skills that were strongly emphasized by both participant categories within this domain included the capacity of a manager to mentor junior staff and to participate in opportunities for continuing professional development and lifelong learning. Skills relating to promoting staff accountability for RAC quality of performance were only reported by participants who possessed a formal health qualification.
In order to promote and sustain quality performance, senior managers who were also qualified health practitioners, emphasised the importance for leadership teams to establish a professional work environment where staff and external health care providers were responsible and accountable to ensuring quality. A Clinical Care Coordinator operating in an inner regional RACF, suggested that reward and positive feedback mechanisms proved an effective leadership strategy to enhance employee accountability for quality assurance. Still of note, promoting staff accountability towards quality assurance was not emphasised by participants who did not possess a health qualification.
“Managers need to devise strategies so that each department is accountable for the health care they provide. This way you are making everyone, regardless of their professional role, accountable for his or her actions. Regularly rewarding and showcasing high quality performance is really important” Clinical Care Coordinator, Regional Facility, ID4.
The capacity of senior managers to mentor junior staff and seek mentorship from respected colleagues, was viewed by both participant categories as an important RAC leadership skill. Of the qualified health practitioners who were interviewed, three Facility Managers reported that management teams required the capacity to mentor and coach junior managers to deliver sustained care quality within an organisation. Also, the willingness and opportunity of senior managers to actively seek mentorship from respected colleagues was suggested as an important strategy to enhancing leadership capacity within a RACF.
“And I guess accessing mentoring was is also important. Accessing other managers, who are really high performers and working ways to integrate this into your routine, can only help professional development” Facility Manager, Rural Facility, ID7.
Managers who did not possess a formal health qualification also reported the importance of actively seeking mentorship from respected colleagues to improve RACF quality systems, as suggested by one General Manager operating in an outer regional area.
“Accessing mentoring was also important. Accessing other managers, and looking at, developing through them”.General Manager, Regional Facility, ID9.
Knowledge of the healthcare environment
Skills and strategies associated with a managers’ understanding of the health care system and environment in which they operate are linked to ‘Knowledge of the health care environment’. Only participants who possessed a formal health qualification emphasised skills within this domain. Four participants, spanning different managerial roles and geographic areas of remoteness, suggested that senior managers require the health knowledge to recognise the scope of practice for each health care profession working within an RACF.
“Every manager should have basic clinical skills that you can continue to build on in whichever direction you need to through education and other avenues. Overall, you need to know that your staff are meant to be doing to ensure a safe, quality service” Facility Manager, ASGS RA 5 – Participant 19.
One Director of Nursing also reported that senior managers required a developed clinical perspective to ensure that organisational decisions regarding quality of care were made with the appropriate insights and knowledge of the health care environment.
“So your clinical assessment and observation skills need to be really on the ball if quality is to prevail” Director of Nursing, Regional Facility, ID17.
Few participants made the link between skills to monitor trends in the local and national health care settings, demonstrate familiarity with the regulations affecting health care delivery, or understand the impact of public policy decisions on cost, quality and access to care. Only one Facility Manager noted the importance of senior managers having the knowledge to assess quality and safety performance, noting it was important for managers to reward positive behaviours for staff who promote safe and quality health care practices. Of note, throughout most participant interviews, service quality was predominantly framed in relation to general business operations, rather than quality of health care per se.
“I always go back and I complement them and I do that often in front of the team at handover, saying this was really good in regards to your safety documentation. You were clear. So, my compliments are also very specific” Clinical Care Coordinator, Regional Facility, ID4.
Information technology and finance
Several participants emphasised the importance of utisling contemporarty information technologies (IT) to assist staff education, quality compliance and reporting. Managers without a health qualification described the importance of financial management skills to ensure cost-efficient service delivery. Skills associated with strategic planning to enhance quality improvement and compliance were less of a focus for all study participants.
Senior managers across both participant categories recommended that senior managers develop the knowledge and skills to effectively utilise IT platforms. One Facility Manager with a formal health qualification recommended that RAC management teams employ innovative IT to deliver staff education about strategies to improve patient quality outcomes and to support the successful integration of new regulations including the new Aged Care Standards. Two managers located in inner regional RACFs reported that education contributed to increased knowledge across the organisation and a greater opportunity for high quality care to be achieved.
The importance of utilising IT platforms to increase RACF efficiency and accuracy with documentation and quality reporting requirements was also emphasised by one General Manager who did not possess a health qualification. Another participant who possessed a tertiary qualification in Business and management experience within the hospitality industry strongly emphasised the importance to recognising the role of finance in quality improvement programs. This participant reflected that senior managers should possess the skills to effectively oversee the RACF financial position and ensure that appropriate resources are available to support high quality of care.
“Yeah so it's about having information systems. So it's important to have a structure where we have a forum where they concentrate on different topics to enhance the skills and knowledge or out staff across multiple areas” Facility Manager, Regional Facility, ID16.
“Senior managers must be aware of IT that can support quality reporting and compliance in line with its unique organisational profile. Senior managers must have knowledge regarding the operation of RACF IT platforms” Facility Manager, General Manager, Regional Facility, ID9.
“If you want to see quality outcomes, you need to know how to budget for quality staff, technology and other resources. Quality health care costs money” Facility Manager, General Manager, Regional Facility, ID18.