ORIGINAL ARTICLE

Validation of a clinical leadership qualities framework for managers in aged care: a Delphi study Yun-Hee Jeon, Jane Conway, Lynn Chenoweth, Janelle Weise, Tamsin HT Thomas and Anna Williams

Aims and objectives. To establish validity of a clinical leadership framework for aged care middle managers (The Aged care Clinical Leadership Qualities Framework). Background. Middle managers in aged care have responsibility not only for organisational governance also and operational management but also quality service delivery. There is a need to better define clinical leadership abilities in aged care middle managers, in order to optimise their positional authority to lead others to achieve quality outcomes. Design. A Delphi method. Methods. Sixty-nine experts in aged care were recruited, representing rural, remote and metropolitan community and residential aged care settings. Panellists were asked to rate the proposed framework in terms of the relevance and importance of each leadership quality using four-point Likert scales, and to provide comments. Three rounds of consultation were conducted. The number and corresponding percentage of the relevance and importance rating for each quality was calculated for each consultation round, as well as mean scores. Consensus was determined to be reached when a percentage score reached 70% or greater. Results. Twenty-three panellists completed all three rounds of consultation. Following the three rounds of consultation, the acceptability and face validity of the framework was confirmed. Conclusions. The study confirmed the framework as useful in identifying leadership requirements for middle managers in Australian aged care settings. The framework is the first validated framework of clinical leadership attributes for middle managers in aged care and offers an initial step forward in clarifying the aged care middle manager role. Relevance to clinical practice. The framework provides clarity in the breadth of role expectations for the middle managers and can be used to inform an aged care specific leadership program development, individuals’ and organisations’ performance and development processes; and policy and guidelines about the types of activities required of middle managers in aged care. Authors: Yun-Hee Jeon, PhD, Associate Professor, Sydney Nursing School, The University of Sydney, NSW; Jane Conway, DEd, Consultant, Medical Education Coordinator and Deputy Director, Sydney Nursing School, The University of Sydney, Camperdown, Medical Education Unit Joint Medical Program, University of New England, Armidale and University of Newcastle, Callaghan, NSW; Lynn Chenoweth, PhD, Professor, Faculty of Nursing, Midwifery and Health, University of Technology Sydney, Sydney NSW; Janelle Weise, MPH, Research Assistant, Sydney Nursing School, The

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010, doi: 10.1111/jocn.12682

What does this paper contribute to the wider global clinical community?

• The Aged care Clinical Leader-

•

ship Qualities Framework (ACLQF) is the first validated framework of clinical leadership attributes for middle managers in aged care. The ACLQF offers an initial step forward in clarifying the aged care middle manager role.

University of Sydney, NSW; Tamsin HT Thomas, MSc, Project Officer, Sydney Nursing School, The University of Sydney, NSW; Anna Williams, MPH, Research Fellow, Sydney Nursing School, The University of Sydney, Camperdown, NSW, Australia Correspondence: Yun-Hee Jeon, Associate Professor, Sydney Nursing School, The University of Sydney, 88 Mallett Street, Camperdown, NSW 2050, Australia. Telephone: +61 2 93510674. E-mail: [email protected]

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Key words: aged care, Delphi study, leadership, long-term care, management Accepted for publication: 02 August 2014

Introduction Internationally, there is a growing recognition of the need to place a greater emphasis on the quality of clinical, individual and organisational leadership and management capabilities in aged care (Jeon et al. 2010a,b). Middle managers are critical intermediaries in the interface between strategy development and implementation, within the challenging contemporary aged care environment. They provide the essential day-to-day link between governance, operational management, care and service delivery (Department of Health Victoria 2010), including monitoring business operations, maintaining standards of care, managing personnel and budgets and facilitating organisational change when needed. The majority of middle managers in aged care, particularly residential aged care, are registered nurses (RNs). Many of those middle managers typify the hybrid manager described by Hewison (Hewison 2006) as having both the professional responsibilities of being a RN and middle management responsibilities within aged care organisations. It has been suggested that this dual responsibility creates role tension for nurses in frontline and middle management positions (Hewison 2004). Providing a framework to operationalise clinical leadership has the potential to reconcile tensions among clinical and managerial responsibilities. In aged care middle managers are responsible for both staff management and organisational leadership. Developing clinical leadership abilities in middle managers would help to support their positional authority in seeking to optimise quality aged care services. However, clinical leadership is illdefined in the aged care setting and the way that it is operationalised depends on the context and on role expectations. There has been no integrated, cohesive framework to guide the development of clinical leadership for aged care middle manager, many of whom have a nondirect clinical role. As well, there is no single reported framework that clearly articulates the role of clinical leadership in generic leadership and management behaviours (Skills for Care 2006). The emergent discourse within the literature suggests the importance of an integrated and complementary understanding of the nature of the concepts of leadership and management, and the need to ensure leadership is embedded in management roles at all levels (Skills for Care 2006). This is particularly

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important in the Aged Care sector as it seeks to enhance quality of care and respond to system wide constraints. Pervasive understaffing and insufficient resources have been identified as the primary constraints on staff confidence in most quality improvement activities. The middle manager’s capacity to reconcile his/her management accountabilities and leadership activity is critical to quality improvement in aged care. This is particularly so as when philosophical cohesion and resources are deficient, leadership in others at the point of care is both unstable and restricted (Brannon et al. 2002, Anderson et al. 2004, Kash et al. 2007).

Background Development of the ACLQF The aged care clinical leadership qualities framework (ACLQF) was devised to support the development of clinical leadership among middle managers in aged care settings in Australia, in response to an identified need to build social capital and workforce capacity within aged care organisations through enhancing the leadership capabilities of managers (particularly middle managers). Middle managers in the aged care sector were defined as those who held administrative, managerial or supervisory positions, including, but not limited to: Assistant/Deputy Directors of Nursing; Care Managers of residential aged care facilities; and team managers/coordinators for community aged care services. Supervisors who did not have managerial responsibilities for a facility, unit or team and executive managers who did not have direct and ongoing interactions with care staff were not considered middle managers. The purpose, content and structure of the ACLQF was informed by a narrative review (Jeon et al. 2008, 2010a, b) which examined individual, policy and system related factors associated with clinical leadership in aged care and identified the attributes required of middle managers to be effective leaders and core principles (Table 1) that needed to be incorporated into the Framework. Following identification of the Principles a set of eight key qualities (each attribute having a set of three to six descriptors) was developed (see Table 2). Development of the Framework acknowledged that effective middle manager capabilities in aged care require the middle manager to be able to use

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010

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Aged care leadership qualities framework

both leadership and management knowledge in providing an integrated response to a range of stakeholder expectations in ensuring in effective and efficient day-to-day leadership and management of aged care organisations. Jeon et al. (2008) found the necessary and desirable attributes and characteristics for middle managers in aged care, which include: • Being goal orientated, responsive to staff and circumstances in a reflexive way and communicating effectively (Larsen et al. 2005). Respectful listening plays a critical role in the considerate communication necessary to sustain staff perceptions of effective, meaningful leadership (McGillis Hall et al. 2005, Morgan et al. 2005, Pearson et al. 2007). An open, two-way flow of respectful, meaningful and considerate communication facilitates flexibility, with problem solving constituting an essential attribute of that flexibility (Hughes 2005, McGillis Hall et al. 2005, Scalzi et al. 2006, Pearson et al. 2007); • Having direct access to staff and professional expertise in nurturing staff respect, recognition and team building (Wieck et al. 2002, Pennington et al. 2003). The presence of middle managers on the practice floor has a positive effect on nurse productivity as the personal experience of a leader is highly valued by members of a team (Fox et al. 1999); a ‘hands-on’ approach is appreciated by all and inculcates a culture of generativity (Pennington et al. 2003, Morgan et al. 2005, Priest 2006); • Aligning the passion of supporting quality care and personal and professional authenticity (Stanley 2006). The effective leader has an engaging style that facilitates their role as mentor and role model, enabling high esteem and empowerment of their staff. Inspirational leaders are enthusiastic and honest (Wieck et al. 2002), optimistic, and model values and ethics that are congruent in their personal manner and professional practice (Deutschman 2005, Large et al. 2005, Scalzi et al. 2006). Through their actions, they transmit organisational values and expectations (Deutschman 2001, Marquis et al. 2004, Mackoff & Triolo 2008);

•

Having the emotional intelligence (Duffield 2005, Gilmartin & D’Aunno 2007, Pearson et al. 2007) and political astuteness (Large et al. 2005, Larsen et al. 2005, Morjikian et al. 2007) to facilitate peer and organisational networking; and • Developing the skills of self-management and self-awareness (Larsen et al. 2005, Scalzi et al. 2006) and the professional expertise to deliver effective clinical supervision (Morgan et al. 2005). In addition to the required attributes of managers, a set of core principles were established based on the narrative review (Jeon et al. 2008) and the core principles underpinned the development of the ACLQF. Core Principles informing the development of the ACLQF. 1 Leadership and management are concepts that have distinct meanings, but their key elements are complementary and overlapping and do so at the point of middle management in particular (See Table 1). 2 In aged care, both leadership and management are directed towards person-centred care (PCC). PCC is both a philosophy and a model of care that underpins aged care practice and is increasingly being embraced by aged care providers, practitioners, policy makers and researchers (Kitwood & Bredin 1992, Kitwood 1997, Edvardsson et al. 2008, Edvardsson & Innes 2010). Ensuring PCC in care delivery requires middle managers to integrate a focus on clinical matters with managerial responsibilities. 3 Change is expected and constant in contemporary aged care, and middle managers are accountable for leading responses to change. An essential function of middle management is to make adjustments to the organisational culture to support effective, sustainable change and quality improvement. Key characteristics of effective change management are identified as having a clear vision and direction, establishing coherence between rhetoric and action, and interactive communication between managers and staff that induces trust, confi-

Table 1 Elements of leadership and management [5, pp.13–14]

Elements of leadership

Overlapping elements of leadership and management

Inspiration, transformation, direction, trust, empowerment, creativity, innovation and motivation

Communication, decision-making, integrity, role modelling [sic], negotiation, professional competence and setting standards

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010

Elements of management Delegation, performance, planning, accountability, finance, teamwork and team building, monitoring and evaluating, formal supervision and control

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Y-H Jeon et al. Table 2 Proposed aged care leadership qualities framework (ACLQF) Item

Quality attributes and descriptors

1 1.1 1.2

(C) Commits to and enacts person–centred care Has a sound understanding of person-centred care as a philosophy of practice and organisational aspiration in aged care Supports the older person through their personal experience of ageing in ways that demonstrate valuing of the person within a social, humanistic approach to care rather than a focus on illness or the functional/cognitive disabilities of the person Promotes the rights of older people and their carers to be valued for their individuality/diversity, experience safety and dignity, and participate in decision-making Demonstrates effective role modelling within a person-centred framework Builds strong relationships within and external to the workplace which facilitate the implementation of person-centred care in aged care (L) Links personal leadership and management behaviours to improved outcomes for older people and the organisation Can identify and describe leadership and management strategies used in personal professional practice Uses a range of outcome indicators to guide personal leadership and management behaviour Understands and works with the diverse interests and views of stakeholders in the aged-care context to optimise outcomes for older people in their care Takes responsibility and accepts accountability for decision-making Demonstrates accessibility and visibility of management to others and develops mechanisms or communication channels to ensure this aspect Is available and approachable for clients, staff and key stakeholders (I) Initiates, monitors and leads improvements in the quality and safety of care of older people Has a deep motivation to improve quality and safety of aged care Uses information in ways that enables identification of areas of strength and areas for improvement in quality and safety of care Determines and justifies priorities and objectives for improvement Leads others to work effectively to design, develop and implement strategies for improvement in the delivery of aged-care services Contributes to developing, testing and reviewing practices, products and equipment (N) Nests decision-making in ethical, legal, regulatory, professional and organisational frameworks Is aware of, and operates within, the range of frameworks pertinent to practice in the aged-care context Leads and manages others in accordance with these frameworks Operates within these frameworks to direct and affect change (I) Influences and participates in the effective management and deployment of human and other resources Identifies, justifies and advocates for resources to optimise clinical care as necessary Uses organisational systems and processes to manage human and other resources Demonstrates business knowledge, skills and acumen appropriate to role of ‘middle manager’ in aged care Contributes to the recruitment, selection and retention of staff to develop and maintain a person-centred service Promotes equality and diversity, safety, security and health within the workforce Coordinates and delegates work and participates in the review of individual and work team performance (C) Collaborates with stakeholders in care processes to optimise clinical outcomes Is self aware and has a fluid and diverse repertoire to engage with and engage others in addressing a range of complex matters, issues and ideas or in complex situations Demonstrates effective interpersonal skills with a range of people in varying contexts Works in ways that facilitate collaborative action through applying team building, emotional intelligence, negotiation, conflict resolution and problem solving skills effectively Leads others through directive decision-making when necessary (A) Accesses and uses evidence to guide person-centred practice Accesses and retrieves relevant information for effective performance in role Uses evidence to optimise quality and safety of person-centred practice in aged care Is familiar with a range of practice, policy and research issues in aged care Works within organisational and professional systems to contribute to evidence-based policy and procedure development Encourages others to use a range of evidence to guide their practice (L) Learns, and develops both self and others Identifies own strengths and limitations Uses feedback on own performance as opportunity for further development Actively seeks and engages in professional development opportunities Demonstrates professional expertise for supervision of others Provides constructive feedback to others about their performance Delivers education and training to others with confidence and ensures content is current

1.3 1.4 1.5 2 2.1 2.2 2.3 2.4 2.5 2.6 3 3.1 3.2 3.3 3.4 3.5 4 4.1 4.2 4.3 5 5.1 5.2 5.3 5.4 5.5 5.6 6 6.1 6.2 6.3 6.4 7 7.1 7.2 7.3 7.4 7.5 8 8.1 8.2 8.3 8.4 8.5 8.6

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© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010

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dence and participation (Marquis et al. 2004, ColonEmeric et al. 2006). 4 Culture change and quality improvement interventions are most likely to succeed with coherent leadership and management (Marquis et al. 2004, Colon-Emeric et al. 2006). In this context risk-taking, transparency and accessibility are encouraged and the manager is valued as the ‘prime driver’ of culture change (Mackoff & Triolo 2008). Fostering a culture of learning through educational opportunities and employee mobility are essential for organisational flexibility in order to respond effectively to change (Mackoff & Triolo 2008). 5 The role of middle managers in managing human and other resources, including budget distribution, must be acknowledged and valued. Key managerial responsibilities include regular and effective staff performance appraisal and career development, which play a strong role in positive perceptions of senior management, better work-life balance and organisational commitment (Borrill et al. 2005). 6 There is a need to adopt and be fluent in the use of technological support systems. Given the competing pressures of increasing consumer demand with concomitant quality improvements and the need to constrain costs, the development of technological support systems for aged care is considered an essential characteristic of organisational leadership (Colon-Emeric et al. 2006, Priest 2006). Middle management fluency in using these systems is pivotal to the success of both themselves and the organisations for whom they work. The first two authors (Y-HJ & JC) mapped the concepts and carefully reviewed and finalised the proposed framework for its completeness and relevance against the six core principles. As indicated in Table 2, the framework uses the acronym ‘CLINICAL’ to define the qualities of middle managers in aged care as leaders. The acronym was considered useful to focus clinical leadership as care of the older person and reinforce the need for middle managers to integrate oversight of clinical care processes with their management accountabilities.

Aged care leadership qualities framework

HREC Database No. 13405). The Delphi technique was used as a widely accepted method of consensus building among experts within a certain topic (Hsu & Sandford 2007, Keeney et al. 2011) and involved: (1) recruitment and consenting of participants to the Delphi panel; and (2) three rounds of consultation on the proposed ACLQF.

Data collection To be eligible for participation, panel participants had to be considered as an aged care expert through current employment within the aged care sector and having relevant knowledge and experience in aged care in terms of clinical practice, management, service delivery, policy, research and/or education. Potential panel participants identified as meeting the eligibility criteria were purposefully sampled from the membership list of a National Aged Care Clinical Leadership Consortium, which was formed as part of a larger study designed to examine the effectiveness of a clinical leadership program in aged care (Jeon et al. 2013). Purposive sampling was used to ensure that rural, remote, and metropolitan settings were represented on the panel. Sixty-nine eligible aged care experts were approached to participate in the Delphi process by email. In total, three rounds of iterative consultation were undertaken with the Delphi panel. In round one, panel members were emailed the proposed ACLQF with a set of instructions on how to rate the relevance and importance of each of the ACLQF attributes and the corresponding descriptors using two Likert scales – one related to the perceived relevance of each Quality attribute (0 = Not Relevant, 1 = Somewhat Relevant, 2 = Moderately Relevant, 3 = Highly Relevant) and the other related to the perceived importance of each Quality attribute (0 = Not Important, 1 = Somewhat Important, 2 = Moderately Important, 3 = Highly Important). Panellists were asked to provide comments concerning each indictor and set of descriptors and to complete a small number of demographic questions concerned with their current position, characteristics of their employing organisation, type of aged care service provider and geographical location.

Methods Data analysis Design In reviewing, modifying and validating the ACLQF, a three-round email based modified Delphi process was undertaken with a group of Australian aged care experts. Approval to conduct this research was granted by relevant ethics committees (BCS HREC Code: EC00432 and USYD © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010

Descriptive analyses were performed for these demographic characteristics. The number and corresponding percentage of the relevance and importance rating for each of the ACLQF attributes was calculated for each consultation round, as well as mean scores as the measure of central tendency, and standard deviations as the measure of dispersion. All

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quantitative data was analysed using SPSS version 20.0 (IBM Corp 2011). A predetermined percentage or mean score of relevance or importance for the ACLQF attributes was not used, so as not to exclude quality attributes in the framework, but instead to indicate the stability of panel responses through the series of consultations (Hasson et al. 2000). In round two and round three, the panellists were presented with the mean scores from the preceding round, and were invited to rate the indicators for relevance and importance using the same procedures as described in round one and to provide comments on the indicators/descriptors, as applicable. Open-ended feedback comments received during each consultation round were used to make modifications to the ACLQF prior to subsequent consultations. Where possible, feedback on the quality attributes by the participants regarding wording or content inclusion/exclusion were used verbatim when making modifications (Keeney et al. 2011). Consistent with the approaches recommended (Keeney et al. 2011),final validity was determined by the mean scores and corresponding standard deviations for each of the attributes and its descriptor, as well as examining the degree of stability of panel responses in the final consultation round, using the combined Likert scores of ‘Moderately/Highly relevant’ and ‘Moderately/Highly important’ for each attribute and descriptor. A proportion of 70% or greater (Keeney et al. 2011) was used as an indication of stability of the participants consensus on ACLQF attribute importance and relevance.

Results Panel characteristics A total of 28 aged care experts performed the role of a panellist in the Delphi process, a response rate of 41% (Fig. 1). The majority of panellists were female (82
1%) and worked in metropolitan areas of the south-eastern states of Australia (New South Wales, Victoria, Australian Capital Territory) (75
0%). Panellists indicated that they worked in a broad range of positions in many different aged care organisations, but more commonly reported working as a Chief Executive Officer (32
1%), or a manager of quality/operations (21
4%),in a not for profit organisation (28
6%), or in an aged care peak body (25
0%). Over one-third (35
7%) of panellists reported previous experience working as an aged care middle manager and had clinical experience as a RNs or allied health professional. Panel members also had experience in both community and residential aged care service provision.

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Panellist responses: importance of the ACLQF attributes and descriptors The majority of participants (>70%) rated the ACLQF attributes as ‘Moderately/Highly Important’ during all consultation rounds, indicating stability of responses from the panel. The only exception was for attribute six during the first consultation round: ‘Collaborates with stakeholders in care processes to optimise clinical outcomes’. Panel consensus concerning this quality attribute was reached at the second round of consultation. Only one panel member gave a rating of ‘Not Important’ for descriptor 8
6 ‘Delivers education and training to others with confidence and ensures content is current’ (round 1 consultation) and another panel member rated descriptor 4
2 ‘Leads and manages staff in accordance with frameworks specific to the aged care context’ ‘Not Important’ (Round 3 consultation). Table 3 shows total numbers and proportions that were found to be ‘Moderately/Highly Important’ or ‘Moderately/Highly Relevant’ for the quality attributes and descriptors across each consultation round.

Panellist responses: relevance of the ACLQF attributes and descriptors As shown in Table 3, all of the ACLQF attributes and descriptors were rated by the majority of the panellists as being ‘Moderately/Highly Relevant’ during each of the three consultation rounds. Only three of the participants considered two descriptors ‘Not Relevant’ or ‘Not Important’ during the consultations. This included two participants concerning quality attribute 8
6 ‘Delivers education and training to others with confidence and ensures content is current’ (Round 1 consultation only); and one participant concerning descriptor 4
2 ‘Leads and manages staff in accordance with frameworks specific to the aged care context’ (Round 3 consultation only). Specific feedback received from panellists that assisted in making content modifications to the ACLQF included the need to: • Clarify terms and expressions used, including: ‘nest’, ‘PCC’, how PCC relates to the issue of patient safety, and ‘stakeholder’ and its use in the framework; • Acknowledge older person’s faith and family as part of PCC and personalise the wording used in the items; • Explicate the goal of the framework as being directed towards embedding the philosophy of PCC across the organisation; • Recognise the importance of collaboration and consultation between middle managers and a diverse range of both internal and external stakeholders including staff,

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010

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Aged care leadership qualities framework

28 (87·5%) participated in Round 1 (4 did not return the survey)*

69 experts in aged care approached to participate in study

Figure 1 Participant recruitment and retention. *Three reminders were sent to those who did not return the survey each Round.

older people and their families. A focus on linking leadership and management behaviours to the improvement of outcomes (quality and safety) for older people, their families and carers, should be an essential component of middle management in aged care; • Focus on the importance of integrating both clinical and business skills such as effective deployment of staff and other resources; • Support the development of a coaching culture related to performance, education and training. It was noted that middle managers need skills to deliver education and training but they also need to be able to facilitate staff access to both internal and external training opportunities; and • Use feedback mechanisms such as quality indicators to measure the impact of leadership and management behaviours. Panellist feedback resulted in the inclusion of an additional descriptor in the ACLQF. This was placed as descriptor 6
2’ Works collaboratively and effectively within and across systems and sectors (i.e. health and social care, and primary, secondary and tertiary care settings) to optimise quality aged care’. In addition, statements defining the quality attributes and/or descriptors were modified. For example, Descriptor 1
5 was reworded to’ Translates the vision of person-centred care to practice through collaboration with older people, their families and staff in order to facilitate the implementation of person-centred care for older people’; Descriptor 8
6 was changed to ‘Facilitates access to internal and external education and training opportunities for staff and supports their career development’; and Descriptor 4
2 became ‘Leads and manages staff and others including volunteers in accordance with frameworks specific to the aged care context.’ Panel consensus maintained stability following these modifications during subsequent rounds of consultation.

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010

32 (46·4%) consented to participate in the study

25 (78·1%) participated in Round 2 (3 did not return the survey)*

37 (53·6%) did not consent to participate in study (no explanation given)

23 (71·9%) participated in Round 3 (2 did not return the survey)*

Validity and stability testing Following consultation in Round 3, the acceptability and validity of the framework was confirmed with the proportion of the participants rating consistently above 80% for both the relevance and the importance of the quality attributes and the majority of the descriptors for each quality attribute; with mean scores ranging from 2
6–3
0 (SD = 0
2–0
7) (see Table 4). Tables 3 and 4 demonstrate how consistently the framework was perceived as moderately to highly relevant and important by the participants across all three consultation rounds. As shown in Table 4, the lowest mean score for the key ACLQF attributes was fairly high (2
6) in Round 1, and increased to 2
8 in Round 3, showing strong approval of the framework from the outset. The final ACLQF following the Delphi consultations contained key attributes and descriptors and the definitions and explanations of the terms (person centred care, clinical leadership, middle managers and stakeholders). This framework was designed to correspond with middle managers’ roles and responsibilities and included management activities as part of clinical leadership work, focusing on both individual and organisational characteristics. The quality attributes were designed to operationalise the core principles, thereby enabling aged care organisations to use the ACLQF as a tool for assessing and/or developing, supporting and evaluating the development of Clinical Leadership within their organisations.

Discussion Through this Delphi evaluation we were able to demonstrate the relevance and importance of the elements of the ACLQF in the Australian aged care context. In Australia, there is an absence of published national data that compre-

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Y-H Jeon et al. Table 3 Proportions of moderately/highly important or relevant for the aged care clinical leadership qualities framework attributes and descriptors over three consultation rounds Round 1 (n = 28)

1(C) 1.1 1.2 1.3 1.4 1.5 2(L) 2.1 2.2 2.3 2.4 2.5 3(I) 3.1 3.2 3.3 3.4 3.5 4(N) 4.1 4.2 4.3 5(I) 5.1 5.2 5.3 5.4 5.5 5.6 6(C) 6.1 6.2 6.3 6.4 6.5 7(A) 7.1 7.2 7.3 7.4 7.5 8(L) 8.1 8.2 8.3 8.4 8.5 8.6

Round 2 (n = 25)

Round 3 (n = 23)

M/H importance (%)

M/H relevance (%)

M/H importance (%)

M/H relevance (%)

M/H importance (%)

M/H relevance (%)

24 27 27 28 28 27 22 26 26 24 27 28 23 27 27 26 28 26 22 27 27 24 24 24 26 25 27 26 26 19 25 N/A 22 28 27 22 26 26 26 26 28 23 27 28 26 28 28 23

24 27 28 28 27 25 22 26 26 24 28 27 23 27 27 28 28 27 22 27 27 25 24 25 27 26 27 25 26 22 26 N/A 22 22 27 21 25 24 25 25 26 23 26 27 26 26 27 22

23 24 24 25 25 25 23 24 24 24 24 24 22 22 25 23 24 22 21 23 25 25 21 22 24 24 22 23 20 22 21 22 24 25 25 20 24 25 21 25 25 22 25 25 25 24 25 24

23 25 24 25 25 25 23 24 24 24 24 24 22 22 25 23 22 23 21 24 25 25 21 23 24 23 22 23 20 22 21 22 24 25 24 21 24 24 22 25 25 21 25 25 25 24 25 24

21 23 22 23 21 23 21 23 23 22 23 23 21 22 23 22 23 21 21 22 22 22 20 23 23 22 22 23 23 21 23 21 23 23 23 19 23 22 21 22 22 21 23 23 23 23 22 23

21 23 22 23 22 23 21 23 22 23 23 23 20 22 23 22 22 22 21 23 22 22 20 22 23 22 22 22 23 21 22 21 23 23 23 20 22 22 19 22 22 21 23 23 23 23 22 23

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7) (95
7) (100) (100) (91
3) (100) (91
3) (100) (100) (100) (82
6) (100) (95
7) (91
3) (95
7) (95
7) (91
3) (100) (100) (100) (100) (95
7) (100)

(91
3) (100) (95
7) (100) (95
7) (100) (91
3) (100) (95
7) (100) (100) (100) (87
0) (95
7) (100) (95
7) (95
7) (95
7) (91
3) (100) (95
7) (95
7) (87
0) (95
7) (100) (95
7) (95
7) (95
7) (100) (91
3) (95
7) (91
3) (100) (100) (100) (87
0) (95
7) (95
7) (82
6) (95
7) (95
7) (91
3) (100) (100) (100) (100) (95
7) (100)

MH, moderately/highly. N/A denotes that this descriptor was added after Round 1 consultation.

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© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010

Original article

Aged care leadership qualities framework

Table 4 Level of consensus for panel participants associated with each aged care clinical leadership qualities framework attribute for the three rounds of consultation

Quality attributes C L I N I C A L

Commits to and facilitates the delivery of clinical care that is underpinned by person-centred care Links personal leadership and management behaviours to improved outcomes for older people and the organisation Initiates, monitors and leads improvements in the quality and safety of care of older people Nests/situates decision-making in ethical, legal, regulatory, professional and organisational frameworks Influences and participates in the effective management and deployment of staff and other resources Collaborates with stakeholders in care processes to optimise clinical outcomes Accesses and uses evidence to guide self and staff to implement person-centred care Learns, and develops both self and others involved in the care of the older person

hensively describes the nature and characteristics of managers within the aged care workforce (Jeon et al. 2008). Studies suggest that middle managers, often nurses in aged care, play a key role in driving a healthy workplace culture, communicating long-term vision, generating global staff satisfaction and building organisational commitment, and recommending organisational investment in leadership through training and the implementation of supportive systems (Aroian et al. 2000, Gagnon et al. 2006, Mackoff & Triolo 2008, Reinhard & Young 2009). The ACLQF is a framework, based on role descriptions rather than professional qualifications and regulation of the industry, which encapsulates these aspects of middle management within the concept of clinical leadership. As such, the ACLQF is the first aged care leadership qualities framework that makes explicit three essential differences between clinical and other leadership roles: 1 The centrality of PCC as the objective of clinical leadership; 2 The integration of strategies to apply and generate evidence-based clinical practice to delivery of care; and 3 The application of theoretical frameworks drawn from clinical professions to guide decision-making. The ACLQF offers an initial step forward in clarifying the aged care middle manager role and, in addition is useful to guide the development of a clear position description for middle managers. It maintains middle managers’ ‘line of sight’ and enables middle managers to be engaged in the building of organisational cultures of © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010

Relevance vs. Importance

Round 1 (n = 28) M (SD)

Round 2 (n = 25) M (SD)

Round 3 (n = 23) M (SD)

Relevant Important Relevant Important Relevant Important Relevant Important Relevant Important Relevant Important Relevant Important Relevant Important

3
0 2
9 2
8 2
8 2
9 3
0 2
8 2
8 2
8 2
9 2
8 2
8 2
6 2
7 3
0 2
9

3
0 2
9 2
8 2
8 2
8 2
9 2
8 2
9 2
8 2
8 2
8 2
8 2
7 2
7 2
9 2
8

3
0 3
0 2
8 2
8 2
9 2
9 2
9 2
9 3
0 3
0 2
8 2
8 2
8 2
8 3
0 2
9

(0
2) (0
3) (0
4) (0
4) (0
3) (0
2) (0
4) (0
4) (0
4) (0
3) (0
4) (0
6) (0
7) (0
6) (0
2) (0
3)

(0
2) (0
3) (0
4) (0
4) (0
4) (0
3) (0
4) (0
4) (0
5) (0
5) (0
4) (0
4) (0
5) (0
6) (0
5) (0
5)

(0
2) (0
2) (0
4) (0
4) (0
5) (0
3) (0
4) (0
4) (0
2) (0
2) (0
4) (0
4) (0
4) (0
6) (0
2) (0
3)

learning and excellence. As a result of this Delphi study, the ACLQF was used to inform the development of an aged care specific leadership program (CLiAC: Clinical Leadership in Aged Care), which is being tested for its effectiveness in improving care quality and workforce capacity in a cluster randomised controlled trial (Jeon et al. 2013). An interim evaluation of the program based on the accounts of the program participants who were considered middle managers in aged care (n = 50), indicated strong support of the relevance and importance of the ACLQF and its elements in underpinning the aged specific clinical leadership program (Conway et al. 2013). This has further provided confidence in our rigorous processes used to validate the ACLQF and helped us confirm the potential of the framework. The ACLQF has policy and practice implications regarding the changing aged care workforce profiles particularly in middle management in Australia. Unlike the UK, Australia has no established qualifications for aged care middle managers. While the majority of residential aged care managers in Australia are RNs, anecdotal evidence suggests that the number of managers who are RNs in aged care in Australia is decreasing, as the position is increasingly being filled by those with another health professional qualification or a nonhealth management background. This trend is largely due to the RN workforce shortage (Productivity Commission 2011). Over the past decade the proportion of RN positions to other categories of workers has decreased while the role has increased in responsibility (Page 2004). It is

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likely that the RN workforce shortage in aged care will take some time to be remedied as it necessitates long-term planning and strategy at both the government and aged care industry level. Whether the professional best placed to fulfil the role of middle manager in aged care is the RN is the subject of much debate and further research is warranted. While the prevailing view of aged care stakeholders and nursing peak bodies is that the RN is the preferred choice for middle manager positions in aged care, there is need for a framework that assists these staff with leadership and management roles. Having access to an evidenceinformed leadership qualities framework will help middle managers to improve their skills and capabilities, particularly those of mentoring and nurturing staff involved in person-centred care and its related clinical activity. Through a systematic process of validation, we have demonstrated the ACLQF has the potential to be applied to middle management in aged care irrespective of professional background. The original review from which the core principles were derived (Jeon et al. 2008) indicates the ACLQF can be highly relevant internationally, in particular among developed countries such as UK, US, Canada, New Zealand and Scandinavian countries. Further validation research could strengthen generalisability of the framework internationally.

tive management and others in aged care contexts with regard how the concept of clinical leadership can be operationalised in aged care.

Relevance to clinical practice Middle managers in aged care have responsibility not only for organisational governance and operational management but also quality service delivery. There is a need to better define clinical leadership abilities in aged care middle managers, in order to optimise their positional authority to lead others to achieve quality outcomes. The ACLQF provides clarity in the breadth of role expectations for the middle managers and can be used to inform an aged care specific leadership program development, individuals’ and organisations’ performance and development processes; and policy and guidelines about the types of activities required of middle managers in aged care.

Acknowledgements We thank the members of the Delphi panel for giving up their valuable time to contribute to this study.

Disclosure Conclusion As the Australian aged care sector prepares for predicted increases in the number of older people requiring support to remain in the community, as well as needing to access residential care, there is an urgent need to address both the quality and quantum of leadership and management in the system. In order to meet the many care and support needs of older people and their families, it will be increasingly important for aged care services to attract, retain and effectively manage aged care personnel, as well provide sound organisational governance. Middle managers are pivotal to achieving these goals. Middle managers in contemporary aged care need to be able to both lead and manage aged care services to optimise outcomes for older people. The ACLQF aligns to middle managers’ roles and responsibilities. It acknowledges that these roles necessitate inclusion of what have traditionally been seen as mainly management activities, and provides a platform for shared understanding among clinicians, middle managers, execu-

The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.

Funding This study is funded by an Australian Research Council (ARC) Linkage Scheme Project in partnership with the Baptist Community Services (BCS) NSW and ACT (Project ID: LP100200198).

Conflict of interest No conflict of interest has been declared by the authors.

References Anderson R, Corazzini K & McDaniel R (2004) Complexity science and the

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dynamics of climate and communication: reducing nursing home turn-

over. The Gerontologist 44, 378– 388.

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010

Original article Aroian JF, Patsdaughter CA & Wyszynski ME (2000) DONs in long-term care facilities: contemporary roles, current credentials, and educational needs. Nursing Economics 18, 149–156. Borrill C, West M & Dawson J (2005) The Relationship between Leadership, People Management, Staff Satisfaction and Intentions to Leave. Aston University, Aston Business School, Birmingham, UK. Brannon D, Zinn J, Mor V & Davis J (2002) An exploration of job, organizational, and environmental factors associated with high and low nursing assistant turnover. The Gerontologist 42, 159–168. Colon-Emeric C, Lekan-Rutledge D, UtleySmith Q, Ammarell N, Bailey D, Piven M, Corazzini K & Anderson R (2006) Connection, regulation, and care plan innovation: a case study of four nursing homes. Health Care Management Review 31, 337–346. Conway J, Jeon Y-H & Edwards C (2013) Implementing a Clinical Leadership Program in Aged Care: The CLIAC Experience. The 25th International Council of Nurses (ICN) Quadrennial Congress, Melbourne, Vic., Australia. Department of Health Victoria (2010) Governing quality in public sector residential aged care: An organisational readiness tool. Available at: http:// www.health.vic.gov.au/agedcare/down loads/pdf/readiness_tool.pdf (accessed 1 February 2011). Deutschman MT (2001) Interventions to nurture excellence in the nursing home culture. Journal of Gerontological Nursing 27, 37–43. Deutschman MT (2005) An ethnographic study of nursing home culture to define organizational realities of culture change. Journal of Health and Human Services Administration 28, 246–281. Duffield C (2005) A master class for nursing unit managers: an Australian example. Journal of Nursing Management 13, 68–73. Edvardsson D & Innes A (2010) Measuring person-centered care: a critical comparative review of published tools. The Gerontologist 50, 834–846. Edvardsson D, Winblad B & Sandman PO (2008) Person-centred care of people with severe Alzheimer’s disease: cur-

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 999–1010

Aged care leadership qualities framework rent status and ways forward. Lancet Neurology 7, 362–367. Fox RT, Fox DH & Wells PJ (1999) Performance of first-line management functions on productivity of hospital unit personnel. Journal of Nursing Administration 29, 12–18. Gagnon S, Rithchie J, Lynch A, Drouin S, Cass V, Rinfret N, Rouleau C & Valois M (2006) Job Satisfaction and Retention of Nursing Staff: The Impact of Nurse Management Leadership. Canadian Health Services Research Foundation, Toronto, ON. Gilmartin MJ & D’Aunno TA (2007) Leadership research in healthcare: a review and roadmap. The Academy of Management Annals 1, 387–438. Hasson F, Keeney S & McKenna H (2000) Research guidelines for the Delphi survey technique. Journal of Advanced Nursing 32, 1008–1015. Hewison A (2004) Management for Nurses and Health Professionals. Blackwell Science, Oxford. Hewison A (2006) Editorial. Middle management and nursing. Journal of Nursing Management 14, 1–4. Hsu C & Sandford B (2007) The Delphi technique making sense of consensus. Practical Assessment Research and Evaluation 12, 1–8. Hughes E (2005) Nurses’ perceptions of continuing professional development. Nursing Standard 19, 41–49. IBM Corp (2011) IBM SPSS Statistics for Windows, Version 20.0. IBM Corp, Armonk, NY. Jeon Y-H, Merlyn T, Sansoni E & Glasgow N (2008) Final Report: Optimising the Residential Aged Care Workforce: Leadership & Management Study, Australian Primary Health Care Research Institute, The Australian National University, Canberra, ACT, Australia. Jeon Y-H, Glasgow NJ, Merlyn T & Sansoni E (2010a) Policy options to improve leadership of middle managers in the Australian residential aged care setting: a narrative synthesis. BioMed Central Health Services Research 10, 190. Jeon Y-H, Merlyn T & Chenoweth L (2010b) Leadership and management in the aged care sector: a narrative synthesis. Australasian Journal on Ageing 29, 54–60.

Jeon Y-H, Simpson J, Chenoweth L, Cunich M & Kendig H (2013) The effectiveness of an aged care specific leadership and management program on workforce, work environment, and care quality outcomes: design of a cluster randomised controlled trial. Implementation Science 8, 126. Kash RA, Castle NG & Phillips CD (2007) Nursing home spending, staffing, and turnover. Health Care Management Review 32, 253–262. Keeney S, Hasson F & McKenna H (2011) Analysing data from a Delphi and reporting results. In The Delphi Technique in Nursing and Health Research. John Wiley & Sons Ltd, UK, pp. 84–95. Kitwood T (1997) Dementia Reconsidered: The Person Comes First. Open University Press, Buckingham. Kitwood T & Bredin K (1992) Towards a theory of dementia care: personhood and well-being. Ageing and society 12, 269–287. Large S, Macleod A, Cunningham G & Kitson A (2005) RCN Clinical Leadership Programme Transforming Clinical Leaders to become Agents of Positive Change. RCN Institute, London. Larsen L, Cummins J, Brown H, Ajmal T, Beers H & Lee J (2005) Learning from Evaluation: Summary of Reports of Evaluation of Leadership Initiatives. Office of Public Management and the NHS Leadership Centre, London. Mackoff B & Triolo P (2008) Why do nurse managers stay? Building a model of engagement: part 1, dimensions of engagement. Journal of Nursing Administration 38, 118–124. Marquis R, Freegard H & Hoogland L (2004) Cultures that support caregiver retention in residential aged care. Geriaction 22, 3–12. McGillis Hall L, McGilton KS, Krejci J, Pringle D, Johnston E, Fairley L & Brown M (2005) Enhancing the quality of supportive supervisory behavior in long-term care facilities. Journal of Nursing Administration 35, 181–187. Morgan DG, Stewart NJ, D’Arcy C & Cammer AL (2005) Creating and sustaining dementia special care units in rural nursing homes: the critical role

1009

Y-H Jeon et al. of nursing leadership. Nursing Leadership 18, 74. Morjikian RL, Kimball B & Joynt J (2007) Leading change: the nurse executive’s role in implementing new care delivery models. Journal of Nursing Administration 37, 399–404. Page A (2004) Keeping Patients Safe: Transforming the Work Environment of Nurses. National Academies Press, Washington D.C. Pearson A, Laschinger H, Porritt K, Jordan Z, Tucker D & Long L (2007) Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in healthcare. International Journal

of Evidence-based Healthcare 5, 208–253. Pennington K, Scott J & Magilvy K (2003) The role of certified nursing assistants in nursing homes. Journal of Nursing Administration 33, 578–584. Priest A (2006) What’s Ailing our Nurses? A Discussion of the Major Issues Affecting Nursing Human Resources in Canada. Canadian Health Services Research Foundation, Toronto, ON. Productivity Commission (2011) Caring For Older Australians, Report No. 53, Final Inquiry Report, Canberra. Reinhard SC & Young HM (2009) The nursing workforce in long-term care. Nursing Clinics of North America 44, 161–168.

Scalzi CC, Evans LK, Barstow A & Hostvedt K (2006) Barriers and enablers to changing organizational culture in nursing homes. Nursing Administration Quarterly 30, 368–372. Skills for Care (2006) Leadership & Management: A Strategy for the Social Care Workforce, Skills for Care. Topss England, Leeds, UK. Stanley D (2006) Recognizing and defining clinical nurse leaders. British Journal of Nursing 15, 108–111. Wieck KL, Prydun M & Walsh T (2002) What the emerging workforce wants in its leaders. Journal of Nursing Scholarship 34, 283–288.

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