We present findings from this qualitative analysis under five inductively identified skill domains including i) workforce development and retention, ii) governance and business acumen; iii) health systems knowledge; iv) stewardship and v) responding to regulatory and political contexts. In the following sections, these overarching domains, and the more specific leadership skills they encompass are referred to simply as ‘domains’ and ‘skills’ respectively to improve clarity. Interview participants are identified only by generic labels (as outlined in Table 1) of ‘consumer advocate’, ‘provider advocate’, ‘Primary Healthcare Network’ or ‘Researcher’.
Workforce development and retention
Skills in this domain included a manager’s ability to develop a workforce with an appropriate balance of clinical skills across the organisation. To achieve this optimal skill mix, a manager’s ability to recruit health care personnel across key service areas, with the knowledge to service a range of complex co-morbidities and psychosocial needs specific to an older demographic, was reported by a majority of participants as critical to quality of care.
The ability of a leader to choose, recruit and retain key people across the core health services areas is so important to delivering quality careConsumer advocate – ID4
Critical to being able to support recruitment and retention, five participants comprising both provider and consumer advocates, additionally noted the importance of human resource management skills; including the ability to negotiate with staff and being compassionate to an employee’s needs within and outside of the workplace.
Human resource management is so essential to making quality health care occur.Provider advocate - ID2
Alongside these more technically oriented skills, a majority of participants including primary health network representatives, consumer and provider advocates, collectively highlighted the importance of a senior manager’s relational skills. Key amongst these was the ability to nurture and build relationships with staff, communication skills and building peer support networks. The ability of senior managers to develop rapport and trusting relationships with staff, for example, was described as promoting open channels of communication among interprofessional teams and thus promoting high-quality care.
So, it's being personable and being able to develop that rapport with your staff so that they trust you and they feel like they can come to see you to discuss anything regarding the health care services that they are responsible for providing.Provider advocate - ID2
Another participant emphasised the importance of a manager’s ability to employ communication skills involving empathy and active listening techniques, as essential to creating therapeutic relationships with residents and their families and to positively influencing care quality.
I think every person who works in aged care, whether they're a leader or not, needs to have good communication skills in order to be able to engage in a therapeutic manner with residents, and so communication skills involve imparting empathy and involve listening.(Researcher – ID9)
External to the organisation, a manager’s ability to build and nurture peer support networks with other RACFs, to share expertise around business models that promote quality of care, improve business knowledge, and receive peer mentorship, was also emphasised as an important leadership skill by four provider advocates:
People should start to build collaborations across other [aged care] organizations … so that they can bring in really top-quality people.Provider advocate – ID5
Make sure that you've got a good peer network around you that you reach out for that support.
Provider advocate – ID8
Governance and business acumen
The ability of senior managers to create a governance structure to delineate power and define management roles in an organisation, was linked to quality of care. Participants viewed this skill as a strategy for managers to set rules, procedures, and other informational guidelines to quality improvement. Researchers, primary health network representatives, provider and consumer advocates reported skills under this domain and linked these to quality of care.
A provider advocate emphasised that senior managers should possess the knowledge to develop an organisational structure that provides executives and managers the opportunity to make informed decisions regarding health care delivery.
The organisational structure must be designed by managers so that they can support themselves … to free up their time to make the best decisions for their health care servicesProvider advocate – ID10
A consumer advocate emphasised the importance of senior managers possessing the skills to successfully lead the operational aspects of an organisation that are linked to service provision, such as compliance management and management of resources.
Again, leaders need to be committed to older Australians and be able to smoothly run high level operations in order to positively influence the quality of their serviceConsumer advocate and Aged Care Advisory group member – ID4
Critical to being able to support the sustainability and quality of RAC health care services, several consumer and provider advocates additionally noted the importance of a manager’s business skills such as financial management, human resource, and people management skills, as a factor contributing to quality of care. As reported by this provider advocate:
So, there's significant financial management, sales significant clinical skills and significant human resources skills, and people management skills that are requiredProvider advocate – ID2
The capacity of a senior manager to be strategic in planning operations was also emphasised as an important leadership skill for RAC in Australia. As described by the provider advocate below, such skills were linked to effective planning to meet challenges and identify opportunities for handling the increasingly complex political, regulatory and clinical landscape of RAC in Australia:
I think being strategic as well. So looking at opportunities and, as you were talking about before, innovation, thinking outside the square to get the best possible care for the resident.Provider advocate – ID6
Health system knowledge
Skills and strategies associated with a manager’s understanding of the health care system and clinical environment were noted by a number of study participants. External to their specific facility, interviewees linked quality performance to the ability of senior managers to recognise the variations between mainstream health care organisations and RAC service provision. Five participants, who were researchers, provider and consumer advocates reported skills under this domain.
One researcher described that the quality of RAC should be focused on maintaining an older person’s quality of life, which required a unique set of leadership skills:
So it is important to recognize the differences between acute care where the focus is on diagnosis and treatment, and aged care, where the focus is more about quality of life. It takes very different managerial skills to effectively manage each context and those who lead these organization’s need to recognise this.Researcher and National Aged Care Advisory Committee member– ID7
In addition to providing oversight to the clinical aspects of RAC, study participants across all expert categories suggested that senior managers should themselves possess clinical knowledge and skills to successfully embed quality health care practices within the organisation. Clinical skills included managers’ ability to recognise effective clinical care models that address the health care needs of an older demographic and the ability to recognise clinical outcomes to care.
I think a problem where we separate out residents needs into biomedical needs, clinical needs and social needs and accommodation needs …. We need a consistent model of care that focuses solely on caring for the individualResearcher – ID9
You must have a keen eye towards resident outcomes, and I would be as broad as to say clinical quality outcomes and customer experience outcomes, all of these clinical attributes are important for a manger to possess and be aware ofProvider advocate – ID 10
One researcher suggested that if senior managers did not possess a sound level of clinical knowledge, then residents’ needs could be missed or neglected.
So, I think the fact that we now have a lot of leaders who don't have any healthcare background has put us in a situation where resident's clinical care needs often missed and neglected.(Researcher National Aged Care Advisory Committee member – ID7)
‘Stewardship’ encompassed leadership skills to create a positive workplace culture through creating a physical environment that encouraged employee wellbeing; promoting team cohesiveness; and helping team members overcome negative industry perceptions.
The ability of a senior manager to create a physical environment that encouraged employee wellbeing, was linked by study participants to positive workplace culture and high-quality care. The skills to promote such a physical environment included the ability to develop a workspace that promotes employee and resident comfort, with one consumer advocate describing the links to employee job satisfaction and retention and resident quality of life:
Coming to work at a place that is comfortable each day will only improve employee performance to delivering quality careConsumer advocate Aged Care Advisory group member – ID4
Leadership skills to promote team cohesiveness were also linked to increased workplace culture and organisational quality performance.
If you have a good leader, you could be working in a positive and cohesive team even though; the situation around you feels quite direProvider advocate – ID1
Additionally, and potentially specific to the Australian context, participants reported the importance of stewardship skills to overcome negative public perceptions regarding RAC (in light of negative accounts heard during the recent Royal Commission into Aged Care Quality and Safety). The capacity to manage such perceptions were also linked to promoting a positive organisational culture and staff retention.
I think probably the biggest challenge is the negativity within the media for the bad cases and the lack of media interest in a good case. So, it is more difficult for them to get and retain staff because of thatConsumer advocate Aged Care Advisory group member – ID4
Responding to regulatory and political contexts
‘Responding to regulatory and political contexts’ included the leadership skills required by senior managers to successfully interpret and respond to Australian aged care regulatory change. Researchers, provider and consumer advocates interviewed as part of this study reported skills under this domain and linked them to quality of care.
Two provider advocates suggested that while the current aged care regulatory environment can be difficult to interpret, that senior managers need to be proactive to lead RAC regulatory compliance. This process was described as senior managers initiating partnerships between regulators and their organisation to ensure a joint approach to regulatory compliance.
Providers do need to actually look at themselves and see how they contribute to improving the overall situation … which would suggest more of a partnership-based approach between regulator and provider rather than a compliance focused approach of seeking out and punishing wrongdoingProvider advocate – ID2
In addition to forming external relationships with regulatory authorities, some participants emphasised that senior managers further develop their lateral thinking skills to assist in interpreting and responding to the evolving aged care regulatory and political context. This includes the ability to recognise and interpret regulatory reform and to successfully translate this change to RAC operations in order to sustain quality health care delivery.
So, I think those external factors really require a leader to be really adaptable, to be mobile, to be a lateral thinker and responsive to the regulatory and political surroundings, in order to be effective for health service deliveryConsumer advocate – ID12