Leadership skills for quality residential aged care: An industry perspective

Background Documented poor quality and standards of care in Australia’s residential aged care (RAC) sector have 48 highlighted a need to better understand the role of, and skills required by, RAC senior management 49 personnel to address these concerns. This study examined which senior management leadership skills 50 are necessary to deliver and strengthen the quality of RAC, with the aim of improving understanding 51 of the professional development needs of leaders in the sector. We conducted 12 in-depth interviews with Australian aged care industry experts, including 54 academics, and representatives from the primary health network, consumer, and provider advocate 55 groups. Abductive, thematic analysis incorporated coding derived from existing leadership skills 56 frameworks as well as inductively identified themes.


Background 74
The global population is rapidly ageing. 1 In 2020, there were approximately 980 million individuals 75 aged 60 years and over and by 2050 this figure is expected to reach 2.1 billion. 1 Australia is no 76 exception, with approximately 25% of the population projected to be 65 years and over by 2057. 2 As 77 population ageing increases in Australia, there has been a concurrent rise in demand for aged care, 78 including residential aged care (RAC) capable of delivering high quality care to older persons with 79 complex co-morbidities such as multiple chronic non-communicable diseases and dementia. 2 Yet, the 80 inadequacies of Australian RAC services made public as part of the Royal Commission into Aged 81 Care Quality and Safety, demonstrated numerous incidences of neglect and substandard clinical 82 services. 3 The same commission identified leadership skills and strategies required by managers to 83 promote quality of care as lacking, by comparison to international RAC services and other Australian 84 mainstream health care organisations. 3

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Leadership can be defined as the behaviour of an individual when directing the activities of a group 87 toward a shared goal. 4 In the context of health care leadership, a skills perspective is often used to 88 identify and describe the competencies (knowledge and skills) required by managers to influence 89 quality of care across multiple settings, including aged care. 5 Importantly, the demands of, and thus 90 skills required by, managers in residential aged care services may differ to other health care 91 organisations. The continuous nature and complexity of clinical services required by care recipients; 6 92 specific regulatory requirements, and facility-level business operations, 7 for example, are indicative of 93 the need for (combinations of) skills somewhat distinct from mainstream healthcare organisations. In 94 Australia, moreover, RAC organisations are operating in a context that includes well-documented and 95 sector-wide underfunding, 8 a slow uptake of contemporary technologies 9 and chronic challenges in 96 recruiting sufficient and appropriately skilled personnel. 6 With the demand for aged care increasing 97 and concurrent concerns regarding the quality of that care, there is a clear need to understand which 98 types and combination of skills are required by managers to provide effective leadership in the 99 complex landscape of Australian RAC organisations. 100 To date, however, no sector-specific skills or competency framework to guide the professional 101 development of Australian RAC managers has been produced. representatives engage with stakeholders across multiple levels of the Australian aged care system, 112 and inform sector-wide policy development and national governance arrangements in various ways. 12 113 Industry experts include academics, primary health network representatives, consumer, and provider 114 advocates who each possess knowledge regarding the health service needs of older persons in 115 Australia. 13 This includes knowledge regarding the types of skills likely needed for the development 116 of leadership training programs for managers to drive best practice for the quality, efficiency and 117 equity of services at national and facility levels. 13 Industry developments, the role and responsibilities 118 of leadership personnel are often considered in the formation of these programs. 14 119 120 With a view to addressing the gap in current knowledge regarding the combination of skills required 121 by RAC managers in Australia, this study aimed to qualitatively explore the views of a range of aged 122 care industry experts regarding the senior management leadership skills required to ensure quality of 123 care. 124

Study design 127
We conducted an exploratory qualitative study to understand, from the perspective of Australian aged 128 care industry experts, the leadership skills and strategies required by RAC senior managers to 129 influence high quality of care. For the purpose of the current study, Australian aged care industry 130 experts are those in a professional role that is either an aged care researcher, primary health network 131 representative, consumer or provider advocate. and 'what' to gain a deeper understanding of participants' views and experiences regarding the senior 136 manager leadership skills that influence quality of care in Australian RAC organizations. 137

Study Setting 138
The current study was completed with representatives who contribute to or advise regarding the 139 delivery of aged care services in Australia. Examples of different 'levels' of care include: i) entry-140 level community-based care at home; ii) higher levels of care at home (Home Care Packages 141 Program) and when living at home is not an option; iii) residential aged care. 15 This study focused 142 specifically on the role of senior managers to providing quality care in the Australian residential aged 143 care setting (RACFs). Residential aged care provides health care services and accommodation for 144 older people who are unable to continue living independently in their own homes. 16 145 146 In Australia, residential aged care providers can span a range of different sectors including religious, 147 charitable, community, for-profit and government organisations. 17  information. Participants were then emailed an invitation for involvement. To be included in the 156 study, participants were required to: i) be aged 18 years and above and ii) be either an aged care 157 researcher, primary health network representative, consumer or provider advocate. 158 159 Overall, 12 in-depth interviews were conducted by the first author (ND) between December 2020 and 160 February 2021, via video conferencing (n=11) and telephone (n=1). Interviews were conducted with 161 provider advocates (n=6), consumer advocates (n=3) researchers (n=2) and primary health network 162 (PHN) representatives who are involved in commissioning Australian aged care services (n=1) ( Table  163 1). Participants also represented national advisory committees including the Aged Care Sector 164 Committee (n=1) and the Aged Care Advisory group (n=2). 165

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The interview guide canvassed the role of the industry expert, their perceived link (if any) between 167 senior managers and RAC quality of care, current and potential challenges associated with delivering 168 high quality RAC, and the leadership skills required to address these concerns. All participants 169 provided written informed consent and agreed to the interview being audio recorded and transcribed. 170 Each participant was provided with a copy of the interview transcription and an opportunity to correct 171 or remove data prior to the analysis. 172 Table 1. Description of participants based on professional role and organisation type 173 174

Data management and analysis 175
Abductive, thematic analysis incorporated coding derived from existing leadership skills frameworks 176 as well as inductively identified themes. To identify major and minor themes, we took the following 177 steps: i) hand written memos were collated immediately after each interview to ensure that a reflexive 178 stance was maintained in relation to the research situation, participants and documents under study; ii) 179 familiarisation through careful and repeat reading of transcripts and research memos, noting emergent 180 themes; iii) each individual participant was emailed a copy of the transcribed verbatim to ensure that 181 the investigators records corresponded with those of the participants from whom those data were 182 derived; iv) open coding in which codes were created based on identified themes, codes were assigned 183 to specific sections of transcripts; v) data display using matrices including summary tables. 184 185

Limitations 186
As with the majority of studies, the design of the current study is subject to limitations. Purposive 187 sampling was used to recruit interview participants, however not all participants were able to 188 interview due to scheduling or other issues. 189 190

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Overview 192 We present the findings under five skill domains including: i) workforce development and retention, 193 ii) governance and business acumen; iii) health systems knowledge; iv) stewardship and v) responding 194 to regulatory and political contexts. In the following sections, these overarching domains and the 195 more specific leadership skills they encompass are referred to simply as 'domains' and 'skills' 196 respectively to improve clarity. 197 198 Workforce development and retention 199 Skills in this domain included a manager's ability to develop a workforce with an appropriate balance 200 of clinical skills across the organisation. To achieve this optimal skill mix, a manager's ability to 201 recruit health care personnel across key service areas, with the knowledge to service a range of 202 complex co-morbidities and psychosocial needs specific to an older demographic, was reported as 203 critical to quality of care. 204 The ability of a leader to choose, recruit and retain key people across the core health services areas is 205 so important to delivering quality care Consumer advocate -ID4 206 207 Critical to being able to support recruitment and retention, several participants additionally noted the 208 importance of human resource management skills; including the ability to negotiate with staff and 209 being compassionate to an employee's needs within and outside of the workplace. 210 Human resource management is so essential to making quality health care occur. Provider advocate 211 -ID2 212 Alongside these more technically oriented skills, participants also highlighted the importance of a 213 senior manager's relational skills. Key amongst these were the ability to nurture and build 214 relationships with staff, communication skills and building peer support networks. The ability of 215 Governance and business acumen 240 The ability of senior managers to create a governance structure to delineate power and define 241 management roles in an organisation, was linked to quality of care. Participants viewed this skill as a 242 strategy for managers to set rules, procedures, and other informational guidelines to quality 243 improvement. A provider advocate emphasised that senior managers should possess the knowledge to 244 develop an organizational structure that provides executives and managers the opportunity to make 245 informed decisions regarding health care delivery. 246 The organisational structure must be designed by managers so that they can support themselves … to 247 free up their time to make the best decisions for their health care services Provider advocate -ID10 248 249 Another participant, who was a consumer advocate, emphasised the importance of senior managers 250 possessing the skills to successfully lead the operational aspects of an organisation that are linked to 251 service provision, such as compliance management and management of resources. 252 Again, leaders need to be committed to older Australians and be able to smoothly run high level 253 operations in order to positively influence the quality of their service Consumer advocate -ID4 254 255 Critical to being able to support the sustainability and quality of RAC health care services, several 256 participants additionally noted the importance of a manager's business skills: including financial 257 management, human resource and people management skills, as a factor contributing to quality of 258 care, as reported by this peak provider advocate: 259 So, there's significant financial management, sales significant clinical skills and significant human 260 resources skills, and people management skills that are required Provider advocate -ID2 261 262 The capacity of a senior manager to be strategic in planning operations was also emphasised as an 263 important leadership skill. As described by this provider advocacy representative, such skills were 264 linked to effective planning to meet challenges and identify opportunities for handling the 265 increasingly complex political, regulatory and clinical landscape of RAC The ability of a senior manager to create a physical environment that encouraged employee wellbeing, 306 was linked to positive workplace culture and high-quality care. The skills to promote such a physical 307 environment included the ability to develop a workspace that promotes employee and resident 308 comfort, with one consumer advocate describing the links to employee job satisfaction and retention 309 and resident quality of life: 310 Coming to work at a place that is comfortable each day will only improve employee performance to 311 delivering quality care Consumer advocate -ID4 312 313 Leadership skills to promote team cohesiveness were also linked to increased workplace culture and 314 organisational quality performance.

I think probably the biggest challenge is the negativity within the media for the bad cases and the lack 324
of media interest in a good case. So, it is more difficult for them to get and retain staff because of that 325 Consumer advocate -ID4 326 327 Responding to regulatory and political contexts 328 'Responding to regulatory and political contexts' included the leadership skills required by senior 329 managers to successfully interpret and respond to Australian aged care regulatory change. Two 330 provider advocates suggested that while the current aged care regulatory environment can be difficult 331 to interpret, that senior managers needed to be proactive to lead RAC regulatory compliance. This 332 process involved senior managers initiating partnerships between regulators and their organisation to 333 ensure a joint approach to regulatory compliance. 334 Providers do need to actually look at themselves and see how they contribute to improving the overall 335 situation … which would suggest more of a partnership-based approach between regulator and 336 provider rather than a compliance focused approach of seeking out and punishing wrongdoing 337 Provider advocate -ID2 338 339 In addition to forming external relationships with regulatory authorities, some participants 340 emphasized that senior managers further develop their lateral thinking skills to assist in interpreting 341 and responding to the evolving aged care regulatory and political context. This includes the ability to 342 recognize and interpret regulatory reform and to successfully translate this change to RAC operations 343 in order to sustain quality health care delivery. 344 So, I think those external factors really require a leader to be really adaptable, to be mobile, to be a 345 lateral thinker and responsive to the regulatory and political surroundings, in order to be effective for 346 health service delivery Consumer advocate -ID12 347 348

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Drawing on interviews with 12 individuals who were Australian aged care industry experts, this study 350 brings new knowledge regarding RAC senior manager skills linked to quality of care. Industry experts 351 satisfaction. 25 Although much of this empirical work is specific to mainstream health care 387 organisations, participants from the current study also linked a manager's ability to recruit and retain a 388 workforce with a diverse skill-set, to increased RAC quality. In addition, many participants reported 389 the skills required to enhance workforce capacity and development, including the ability of managers 390 to promote an organisational culture and physical environment that supports employee wellbeing and 391 promotes job satisfaction. A balanced practitioner skill-mix and healthier organisational culture was 392 found by Braithwaite, Herkes, Ludlow, Testa & Lampree (2017) 26 to positively influence health care 393 outcomes, such as reduced mortality rates and increased quality of life. 394 Although findings from the current study provide an important first step in addressing the evidence 395 gap relating to leadership skills required by senior management personnel in Australia's RACFs, we 396 recognise that they are not comprehensive. Recently, for example, The Royal Commission into Aged 397 Care (2021) 3 found that Australian aged care services were not meeting the needs of culturally and 398 linguistically diverse residents, stating that the existing system did not adequately provide care that is 399 'non-discriminatory and appropriate for people's identity and experience. 3 Leadership skills required 400 to lead culturally sensitive and diverse services were not reported as part of the current study, yet 401 empirical evidence suggests that the ability of a health service to be responsive to the attitudes, and 402 circumstances of care recipient that share a common and distinctive racial, national, religious, 403 linguistic, or cultural heritage; as influencing quality of care and other health related outcomes. 27 404 While findings from the current study draw on expert knowledge of the industry and provide highly-405 contextualised evidence of the types and combinations of skills required, therefore, we recognise 406 further work will be important to further develop understanding of the field. 407

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With the demand for aged care increasing and concurrent concerns regarding the quality of that care, a 409 better understanding regarding the leadership skills required to optimise quality performance is 410 urgently required. The lack of any professional development framework to guide acquisition or 411 updating of those skills is a concern; and overall, there remains a poorly defined link between quality 412 of care and leadership in the context of Australian RAC. This study aimed to reduce this evidence gap 413 and examine which senior management leadership skills are necessary to deliver and strengthen the 414 quality of RAC. Findings demonstrated that Aged care industry experts view the skills required to 415 develop a competent health care workforce and manage relationships with key stakeholders as critical 416 to ensuring service quality; however, the ability of senior managers to lead a quality service for 417 culturally and linguistically diverse care recipients, was not strongly defined. With ongoing concerns 418 and challenges to RAC quality of care, more work is needed to prepare senior management personnel 419 with the appropriate skills to positively lead quality care within Australia's complex RAC setting. 420 Declarations 421

Ethics approval 422
Ethical clearance was obtained from the James Cook University Human Research Ethics Committee (H6652) in 423 August 2019. All participants provided written informed consent and agreed to the interview being audio 424 recorded and transcribed. Each participant was provided with a copy of the interview transcription and an 425 opportunity to correct or remove data prior to the analysis. All methods were carried out in accordance with 426 relevant guidelines and regulations.

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Consent for publication. 429 All participants provided verbal and/ or written consent for data to be published.

Availability of data and materials 431
The datasets used and analysed during the current study are available from the corresponding author on 432 reasonable request.