Gibraltar in the Context of Elderly Care Homes

¶ … Management Performance Within Elderly Care Homes in Gibraltar

The elderly nursing community in Gibraltar is dispersed and characterized by different institution specific challenges and particularities. The current project assesses the general level of leadership competencies within three pre-selected institutions, the management performance assessments of employees, the basic leadership skills required and formulates a series of recommendations as to how these competencies could be obtained. The approach is predominantly a quantitative one, combining various research methods, such as the questionnaire, the case study and structured interviews.

With the aging of the population, more pressure is placed on the health care system throughout the world, and Gibraltar is no exception. As 15.41 per cent of its population is aged over 65 years (Website of the Central Intelligence Agency, 2015), a question arises regarding the country's ability to provide adequate care for its aging population. In this sense then, the current project sets out to assess the elderly care system currently in place in Gibraltar through a managerial standpoint, to assess its current competencies and to provide recommendations for future

Much emphasis has been placed on the health care system throughout the past recent years, due to the numerous changes and pressures faced by the sector, such as inequities in the globalised world, ecological, demographical and socioeconomic changes, global partnerships for social development, disease control and renewed action for primary health care. In such a complex context, the responsibilities of the nursing workforce are a core component to the adequacy of the care management practices, especially due to their ability to reduce inequalities, increase the access to medical care and promote quality and safe care.

The training of nurses then plays a quintessential role in the provision of quality health care, as well as in the composition and dynamics of the nursing workforce, the quality and appropriateness of care and the development of institutional capacity in health (Arras, 1995). The nurse / or professional demonstrates competence when applied effectively a combination of knowledge, skills and clinical judgment in daily practice or job performance. Management of nursing care should be conducted by a professional nurse and technical and managerial skills in the field of care to have the powers to organize, monitor, evaluate and promote the improvement of the quality of nursing care. So the concept of Care Management as the stable union of two words - management and care - meaning itself and greater than the sum of its parts arises (Wilson, 2015).

Thus, for the proper management of nursing care, implementation of management actions and nursing administration is required. In nursing home for elderly people, performance management is important to organize care through the allocation of sufficient resources. But this is not enough, since elderly care should integrate a true and deep caring for patients, not only the management of care - nursing homes should manage to care, not only exist to manage. This approach is important since it indicates how best to organize resources in order to provide humane care.

1.2. Problem statement

Leadership is defined as the process or art that involves the influence to make people voluntarily strive towards achieving the objectives of the group. It includes knowledge, skills and abilities that allow the leader to direct the forces of those who are around in a collective effort through effective and strategic collaboration, negotiation skills, oral and written communication high-level development and team motivation and decision-making (Reid & Weller, 2010). As part of the leadership skills and teamwork, it is expected that the nurse can communicate in a style of appropriate values which support the health system and the nursing workforce, and which are consistent with a healthy work environment (Reid & Weller, 2010).

Management skills and leadership are recognized as an essential part of the practice, not only nurses but also for all health professionals whose development will enable an outstanding healthcare for the future (Reid & Weller, 2010;Cummings et al., 2010; Calhoun et al., 2008). The goal of any health care organization should be to influence the quality of patient care and nursing leadership plays a key role in encouraging staff to gain a better understanding of the patient. Germain & Cummings (2010) show in their research that the nursing leadership style has an impact on nursing performance. From this review, the factors that nurses perceived as motivators for good performance include autonomous practice, labour relations, access to resources, the individual characteristics of nursing and leadership practices. Understanding these factors is a necessary condition for quality nursing care and positive patient and organizational outcomes (Germain & Cummings, 2010; Wong & Cummings, 2007).

Therefore, it is the responsibility of academic nursing and health organizations to continue studying and teaching this subject. Managing the performance of elderly home in Gibraltar is a daunting task which needs leadership skills, training skills and management skills. Thus, nursing home management performance requires that nursing homes for elderly in Gibraltar be managed with multiple competencies and skills.

1.3. Purpose of the study

In the context so far present, the purpose of the current study is that of exploring and understanding the management performance of nursing homes for the elderly in Gibraltar. The scope then is that of revealing how these nursing homes are managed through the use and employment of the most appropriate leadership competencies. Subsequently, the scope of the study is that of answering four specific research questions and therefore supporting the further development and improvement of elderly care in Gibraltar.

A secondary purpose of the study is that of adding to the current body of literature on the traits of elderly care in general and in Gibraltar, in particular. This specific topic of health care in the region is only limitedly addressed within the literature, meaning that the current project will then add more useful data on the subject. This virtually means that the current projects aims not only towards a better understanding of the sector of elderly care in Gibraltar, but also to a better understanding of its theoretical stance and the promotion of further research in the field.

1.4. Research objectives

The current study on the assessment of the managerial competencies in the elderly care facilities in Gibraltar seeks to attain the following four research objectives:

To assess the general situation of nursing homes for elderly in Gibraltar from leadership competencies perspective;

To explore the assessment of the management performance of employees in nursing homes for elderly in Gibraltar;

To evaluate the basic leadership competencies required to manage nursing homes for elderly in Gibraltar;

To recommend such competencies and skills of leadership which will help to better manage nursing homes for elderly in Gibraltar

Aside from these four specific research objectives, another scope is that of raising awareness of the problems encountered by the elderly care sector in Gibraltar, within both the academic and the care communities. The issue of elderly care is becoming more and more important within the modern day society due to the multitude of social, economic and technological changes and the current project seeks to raise awareness of its problems in order to stimulate improvements within the actual sector, as well as more study and attention from the research community.

2. Literature review

2.1. Introduction to the literature review

The literature review section is the starting point of any research processes since it completes a thorough analysis of the available literature in terms of nurse care, elderly care, nursing appraisal systems and other topics related to the studied issue, as these are available within the literature. The shortage of the literature section is that is presents general data from the available sources, without direct reference to the aspects of evaluating the management performances within the elderly care facilities in Gibraltar. Nevertheless, the specific issues are further on addressed through the actual study of the topic via primary and secondary research, and the literature review represents the general theoretical context against which the future research is set.

2.2. Review of nursing qualifications

The increased severity of patients, decreased hospitalization time and the proliferation of care technologies have increased the need for nurses with specific skills that enable them to adapt to these changes and meet the challenges that entails. In general, studies that analyze the focus nursing competencies as essential to ensure health care for their readiness are safe, quality and essential aspects of practice that affect users, families and other nurses (Cathcart et al., 2010; Tabari et al., 2007).

Benner (1982) defines five levels of competence development in nursing:

A novice nurse, or a beginner

Advanced nurse

Proficient nurse

Capable nurse and An expert beginner nurse

The author recognises the novice nurse competence to implement tasks through knowledge of attributes that do not require previous experience owning, i.e. tasks requiring only theoretical knowledge for execution (knowledge in action). Furthermore, the nurse advanced beginner is one that demonstrates acceptable performance level, can perform more complex tasks where at least a minimum level required prior experience a similar situation. At these levels, the nurses need support in clinical performance and also they need help to establish the priorities, as they are not yet able to identify what is most important.

The competent nurse is one that has two to three years of experience, he is able to begin to see their actions as plans or long-term goals and contemplates problems in an abstract and analytical way. Their practice is based on flexible responses produced by the changes and patient needs. The competent nurse is able to make conscious and deliberate planning, which helps achieve a level of efficiency and organization in carrying out their work; they can also coordinate complex demands and make decisions (Benner, 1982). The competent nurse is able to analyze the situation and realize when normality is absent. They are also able to understand holistically a situation which improves decision making (Benner, 1982).

The nurse expert level is the highest development of competition; they have has an intuitive and profound understanding of the situation due to the enormous experience and adaptability. The performance of the expert nurse is integral, not procedural fractionated as beginner, and there is a link between clinical and ethical reasoning (Benner, 1982).

2.3. Review of leadership and managerial competencies

In the study of Tabari et al. (2007) on the development of skills in nursing conclude that this is a very integrated, constant interaction process in which the nurse has the primary role in driving the same. This process of development of competence in nursing is called "the process of constant interaction" and has five main phases:

1. Recognition of the driving force that acts as the reason for the movement of nurses towards the development of competition;

2. Provision of appropriate requirements, sufficient theoretical knowledge and support to meet minimum requirements in order to participate in an activity needs;

3. The experience at the heart of the development process of competition that provides an opportunity to make a link between theory and practice;

4. Consolidation as complete mastery of the proposed work primarily through repeated practice and coping through reflection;

5. Integration incorporating new skills with the old, and prepared to teach and supervise in other related areas.

The authors reiterate that these stages are interconnected instead of having a chronological order, and that the nurse may experience different stages of this process in different jobs simultaneously. In addition, some differences between management and administration are identified; management is a broad concept and relates to decisions about financial and political aspects. Mowinski (2007) makes a review of the literature that finds that leadership competencies addressed almost twice that of management in contrast to the similarity between leadership competencies and management. Of the top ten competencies which are common for nursing home management and leadership are:

Interpersonal skills

Critical thinking

Communication

Management skills (planning and organization)

Business skills (finance and marketing)

Start change health knowledge and health care.

In turn, of the ten competencies mentioned, only two are identified as exclusive leadership: setting the vision and the ability to develop people. They also identify only two exclusive competence management: human resource management and information. This array of skills is important because it provides evidence that opposes the above distinctions between leadership and management.

Some may argue that the merger of leadership skills and management tends to ignore the different objectives that point each. By contrast, Mowinski (2007) suggests that the convergence of leadership skills and management could reflect a different dynamic, determined by changes in the social context of health. Moreover, the wide range of competencies identified in this review verifies that "the role of nursing administrator is expanding and skill set required is immense.

Moreover, Cummings et al. (2010) in their systematic review that included ten databases and 34,666 items, with the aim of exploring the relationships between various leadership styles and outcomes for nurses and their work environments, found that leadership styles focusing on people and relationships as leadership transformation, resonance and support, among others, are associated with greater job satisfaction nurse.

There were also some managerial tools which were associated with higher satisfaction among the nursing personnel and these included: planning, programming, service management, coordination, teamwork, negotiation, managing supplies, supervision, training and recruitment. Also, at an institution wide level, the necessary elements to ensure the adequate functioning of the care facility and, absence of which leads to decreases in staff satisfaction, include: the general skills required as health care, legal regulations, health targets and financing; public health, management control, conflict management, decision making and prioritization of problems.

2.4. Nurse competencies

Several studies have established the skills to be developed by the nurse, among which are those of leadership as communication, teamwork and motivation; and management as delegation and supervision (Reid & Dennison, 2011;Supamanee et al., 2011). It also has attempted to identify factors that might be associated with the effectiveness of the directors or executive nurses, finding a significant relationship attributes as collaboration in multidisciplinary teams, business skills, people management skills, provide nurses with tools and adequate resources to do their jobs, nursing knowledge, quality management and project (Kirk, 2009).

The nurse, in work performance, uses clinical judgment in the provision of services to enable people to improve, maintain or regain their health. The nurses increase the patients' ability to able to cope with health problems, and thus to achieve the best possible quality of life, whatever their illness or disability, to death (Royal College of Nursing, 2003). This implies a particular mode of nursing intervention that relates to empowering people and helping them attain, maintain or regain independence.

Nursing is an intellectual, physical, emotional and moral process that includes identifying the needs of nursing, therapeutic interventions and personal care, information, education, counselling and physical, emotional and spiritual advancement. In addition to direct patient care, nursing practice includes management development, teaching, politics and knowledge (Royal College of Nursing, 2003). All nurses have in their minds a personal discipline concept about what is, what it does and how to do their job. The problem, at least in the UK, is that this concept has not been sufficiently described and analyzed. It is unclear, therefore, whether all nurses share a common concept, much less if it has been shared with patients and the public (Royal College of Nursing, 2003).

In theory, from beginner to expert, Benner (1982) studies the practice of clinical nursing to describe practical knowledge that has allowed the development of research in nursing, and has subsequently changed structures for training future professionals in various fields and creating empirical indicators that favoured the union between theory and practice. Regarding the level of importance of management and leadership of nursing, Meteroja (2004) recognizes seven categories of competencies of nurse-based model. These categories were validated by literature review and by six groups of experts consulted. A scale of nursing competencies which resulted in a very strong validity was built. Among the seven categories related functions appear in the second administration frequency of use, after helping role (Meretoja & Koponen, 2012; Meretoja et al., 2004).

2.5. Organizational appraisal of nursing competencies

The specialized literature on the topic of assessing the performances of nurses is homonymous that there is an increased need to create adequate and well structured systems that identify and assess the performances of the nurses across various care institutions. Nevertheless, the topic is highly complex and despite it being a commonly accepted fact that there is a need for it, its actual development and implementation are tedious processes. Nikpeyma, Saeedi, Azargashb and Majd (2014) for instance assessed the appraisal system within a large teaching hospital in Tehran and found out there existed a multitude of problems that prevented the implementation of an adequate appraisal system. These problems included:

Contextual problems, such as a "disharmony" between the duties of the nurses and the standards imposed on them, inadequate motivation for nurses or organizational shortages which prevent the nurses from properly and efficiently completing their responsibilities, such as equipment shortages

Problems related to the structure of the appraisal system, such as subjectivity of appraisals, inefficiency in the laws and regulations implemented by the organizations and based on which standards would be set and appraisals would be conducted, or a significant gap between the clinical practice required that a nurse complete and the actual theoretical training he/she had received

Problems related to the processes of performance appraisals for nurses, such as an insufficient supervision from managers, unfair and subjective appraisals, as well as discontinuations in the appraisal efforts

Challenges related to the results of the nurse performance appraisal efforts, such as situations in which the appraisals had been conducted by inadequate people and the results were therefore unreliable, or even situations in which the results were based on unreliable feedback received (Nikpeyma, Saeedi, Azargashb and Majd, 2014).

Despite the challenges encountered in terms of nurse appraisals, care facilities across the world are still encouraged to develop their own systems which best respond to their specific needs and challenges. In this sense, the primary mention is that for the institutions to maintain flexibility (Miler and Drake, 1980) and to persist in their efforts to develop and implement the adequate appraisal systems. Needleman, Kurtzman and Kizer (2007) argue that the importance for appraisal systems is based on the fact that the quality of the nursing act influences the safety of the patients admitted within the respective care institutions, the general quality of the health care provided and the patient results which derive from this, as well as the working environment among the nursing staffs. And since most institutions already have in place appraisal systems, the authors recommend the strengthening and improvement of such systems, at all levels of the nursing and care institutions, and through consistent development of working procedures, standards and infrastructure:

"Sustaining and strengthening current efforts requires developing measures that address all the domains of nursing, addressing technical issues needed to analyze the impact of nursing on patient safety and health care outcomes, developing data systems that provide the information needed to implement the model system, regularly improving the set of endorsed standards to reflect the most current science and empirical evidence, and persuading all health care stakeholders that measurement and reporting nursing-sensitive standards make a difference in the care and quality that are delivered. Each of these tasks requires substantial development work and construction and maintenance of the infrastructure to sustain the performance measurement efforts" (Needleman, Kurtzman and Kizer, 2007).

2.6. Summary of the literature review

An important component in the assessment of managerial performances in elderly care is represented by an assessment of the skills and knowledge possessed by the nurses attending to the elderly patients and residents. In this sense, five specific categories of nurses were identified, as follows: a novice nurse, an expert novice nurse, an advanced nurse, a proficient nurse and a capable nurse (Benner, 1982). These categories are set apart by clear differences in responsibilities assigned, previous knowledge and expertise as well as managerial expectations.

In terms of the managerial and leadership assessment of elderly care, the literature review points to several discussions which distinguish between management and leadership, seeing leadership as differentiated by its role to set a vision and develop people, whereas management is characterized by a distinctive role to manage information and the human resource (Mowinski, 2007). A common issue nevertheless with the appraisals and competencies is represented by the absence of a universally accepted model, but the existence of several model and propositions within the general and specialized literature.

The literature hereby presented - a significant and relevant share of the available literature - is sufficiently eloquent to represent a starting point in the analysis and evaluation of the elderly care in Gibraltar. This is true since the matter of quality nursing care is representative and important throughout the world, but the literary sources on the matter do reveal a shortage in that they only look at the objective aspects of care on managers and nurses, without considering that the act and quality of the care services could also be influenced by the patients (Sidani and Epstein, 2003).

3. Research methodology

The research methodology section focuses on the mechanisms employed to complete the study on the evaluation of the management performances within the elderly care institutions in Gibraltar. These research method include the qualitative approach to study, completed with some quantitative data collected through a questionnaire. The data would also be collected through semi-structured interviews, observations and case study assessments.

3.1. The research method

The research methodology hereby employes is directly linked to the nature of the research objectives, meaning that it has been uniquely developed to best collect the particular information required to answer the research questions. In other words, to assess the leadership competencies in elderly care, the evaluation of the staffs, the competencies required and be able to formulate the necessary recommendations, the study employs a combination of qualitative and quantitative research methods, in which data is collected from both primary and secondary sources.

The combination of qualitative and quantitative data in a research method is traditionally known as triangulation and its primary advantages are that it adapts the research method to the specific needs of a given project, but also that it helps reduce the disadvantages of the qualitative and quantitative models, while also maximizing their advantages. This method of research is not only efficient in collecting the necessary data from a multitude of sources, but it also increases the validity and reliability of the study and its findings (Newman and Benz, 1998).

Within the health care community, researches are often conducted with the employment of the triangulation method due to its previously mentioned advantages. For instance, Speziale, Strebert and Carpenter (2011) state that "using two unique methods in one study can explicate realities of the complex phenomena of concern to nursing that might remain illusive if researchers used either method alone."

The qualitative methods employed throughout the study include interviews with the employees in the elderly care system in Gibraltar, as well as the observation of various situations within the institutions and the collection of data from other sources. The interviews and observations will collect primary data, but the research will also employ the collection of secondary data with the use of the case study. The case study is a popular and useful research tool since it offers deeper contextual analysis of the topic researched, as well as observations of particular situations and the possibility to identify relationships between various factors relevant to the research (Soy, 2006). With the use of the case study, secondary data will be collected from a multitude of sources, including reports, journal articles or technical papers.

In terms of the quantitative methods to be employed in the evaluation of management performance in the elderly care institutions in Gibraltar, these include the questionnaires developed specifically for this study and the means in which they are processed. This data will be obtained through primary sources of information, namely the employees in the elderly care system in Gibraltar, both the personnel as well as the managers

3.2. Sampling

The choice of employees for sampling is based on the fact that employees are working at care homes thus being exposed to day-to-day performance, by embarking on a data collection exercise comprising of questionnaires and Semi-interviews, on a section by section approach as well as on a one-to-one basis where necessary in gathering first hand information on the effects and personnel experienced when working under the present management system.

This will form part of Primary source and will include employees of all ages and level of job responsibility.

Sampling will be undertaken using the stratified random sampling approach due to the method of classification involved and ensure employees are accurately represented. This will allow interviewees to explain their responses provide in-depth information where necessary. This will be a useful tool to obtain employee and manager perception.

Questionnaires will also be used as a collection tool to obtain data from the sample because of its minimal cost and resource requirement as well as the ability to capture wide samples within a specified time frame makes it a very useful tool. It is intended to use qualitative methods in data collection; this will be adjusted to meet the criteria of quantitative research. Brewerton and Millward (2001) cite the work of Breakwell, 1995 who states that interviewing is an extremely flexible research tool which can be used at any stage of the research process to identify areas for more detailed exploration, generate hypothesis or as a main mechanism for data collection.

In terms of the actual sample selected, this is formed from 100 individuals working within the elderly care system in Gibraltar, characterized by the following:

80 of the respondents are employed in nursing care and 20 are managers within the system

All respondents willingly answered the questions and their identity is protected

The respondents are employed in three different elderly care institutions in Gibraltar. Two of the institutions were independent and dedicated homes for the elderly, whereas the third one was a special wing in a hospital, dedicated to the care of the elderly.

Out of the 100 respondents, 85 per cent of them were female and 20 per cent were male. The majority of the nurses were female, with some male nurses helping out with the more demanding responsibilities (nurses also receive help from orderlies, who are almost all male, but these were not interviewed for the current study).

In terms of age structure, more than half of the nurses interviewed were young and middle aged (It was later observed that there is a high burnout rate among the nurses and that some of them request early retirement).

3.3. Analysis Technique

When data from interviews, questionnaires and extensive review of literature in this area of study have been generated, the next stage will be the analysis of this data. Qualitative data will be organized, analyzed and interpreted to generate information needed to satisfy the study within the established theoretical framework. The primary data collected will be analysed by using content analysis technique. The research process maintains reliability of research by maintaining the accuracy of research techniques and procedures. The validity of the research is checked by analysing how research will achieve its goals. The generalisibility of research is maintained by checking how the findings are using generally. The ethical measures are applied by giving a consent form by each participant which will depict that participant will take part in the research without any pressure.

3.4. The questionnaire

The questionnaire is an important and highly popular research tool, due to the multitude of benefits it reveals. For instance, the questionnaire is versatile and practical and, within the current context, it is highly beneficial as it will be used to collect data from both nurses and managers, in order to easily retrieve the necessary feedback from two distinctive sources. Then, the questionnaire is also beneficial since it creates quantitative data which is then useful to create a more structured assessment of the problem. The results retrieved through a questionnaire based approach can easily be processed and interpreted to in the context of the particularly assessed situation, but also in comparison to the available literature or other data (University of Surrey).

In the particular context of the current research, the questionnaire would be handed out to 100 hundred respondents, all employed in the elderly care system in Gibraltar. These respondents would voluntarily and anonymously answer the questions asked in the questionnaire, and the data collected would further on be processed to assess the potential problems in the care system, but also to reveal if there exist discrepancies between the perceptions of nurses and those of management. The questionnaire devised for this purpose is composed of ten questions, all revealed below:

Question 1: Please state your occupation within the elderly care system:

a. Nursing care

b. Management

Question 2: How would you, as a nurse, describe your level of qualification:

a. A novice nurse, or a beginner

b. An expert beginner nurse

c. Advanced nurse

d. Proficient nurse

e. Capable nurse

Question 3: How would you, as manager, describe the competencies of your nursing staffs (in percentages)

a. A novice nurse, or a beginner %

b. An expert beginner nurse %

c. Advanced nurse %

d. Proficient nurse %

e. Capable nurse %

Question 4: How do you, as a nurse, develop your competencies for the job?

a. Through education and the possession of an adequate degree

b. Through clinical experience

c. Through training programs

d. Through other measures

Question 5: How do you, as managers, believe that nurse competencies are developed?

a. Through education and the possession of an adequate degree

b. Through clinical experience

c. Through training programs

d. Through other measures

Question 6: As a nurse, which leadership competencies do you consider of major importance within the elderly care institution in which you currently work?

a. Guidance from the leaders

b. A leadership vision and mission

c. Efficient and transparent communications

d. Continuous learning and development

e. Managing change effectively

f. Influencing others

Question 7: As a manager, which leadership competencies do you consider of major importance within the elderly care institution in which you currently work?

a. Guidance from the leaders

b. A leadership vision and mission

c. Efficient and transparent communications

d. Continuous learning and development

e. Managing change effectively

f. Influencing others

3.5. The interview questions

The interviews conducted with managers in the three elderly face facilities in Gibraltar were structured around six questions, and each of the interviews lasted for about half an hour. Each manager was asked the respective questions and then listened to while they gave their open answers. Where necessary, additional questions were posed for clarification purposes. The scope of the interviews was to gather primary data from the managers in a semi-structured manner that allowed them to discuss openly what was of importance within their institutions, both by answering the questions, as well as by providing their own input aside from the initially posed questions.

While the questionnaires had been answered by all targeted respondents in the study sample, the same cannot be said about the semi-structured interviews with the managers, since only 10 managers were able to attend the discussion. This is explained by the fact that the managers are overloaded and often unavailable for discussion with people outside of their institution. Nevertheless, the number of ten managers who were able to attend the interviews and provide answers to the posed questions is sufficient since their answers reflect the situation present within the entire elderly care sector in Gibraltar.

The questions for the structured interview with the managers are as follows:

Interview question 1: What is your general opinion of the general situation in your institution, from a leadership competencies standpoint? From your point-of-view, what leadership competencies are required within your institution and how well are they met?

Interview question 2: Do you currently have in place any systems to stimulate the participation of nurses in the managerial act?

Interview question 3: How would you describe the commitment of nurses to the performance of their care for the elderly?

Interview question 4: Do you currently have in place any systems to assess the managerial performances of the nurses within your institution?

Interview question 5: How would you describe the employee turnover rate in your institution? Do you see this turnover rate as a problem?

Interview question 6: What leadership skills do you think are required to improve the overall performances within your institution?

4. Findings and discussion

The section on the findings and discussion over the performance management in the sector of elderly care in Gibraltar is organized around the findings generated by the different methods of research employed. Specifically, the first section is dedicated to the presentation and analysis of the findings from the data collected with the aid of the questionnaire; it is then followed by the presentation and discussion of the findings generated through observations, to then come to an end with a discussion of the findings generated through interviews with the management. The case study method is employed twice throughout the section in order to provide more input on the specific issues addressed at the various stages of the data discussion.

4.1. The questionnaire data discussion

The questionnaire was completed by a previously selected sample of 100 respondents, 20 of them being managerial staffs and 80 of them being nurses. All answers were valid and no conflicting issues were incurred, meaning as such that all answers collected are reliable and included in the data discussion.

4.1.1. Nurse competencies qualifications

The first question of the questionnaire was posed in order to assess whether there were differences between the perceptions of management and the perceptions of nurses regarding the same issues. The underlying idea of this data collection artifice was that of identifying discrepancies between the two categories of caring staffs and them seeking to create recommendation to unite the two parties in order to better attain the organizational objectives.

And a first and important discrepancy was observed in terms of the perceived levels of nurse competence. In other words, the nurses perceived themselves as less equipped and skilled to handle everyday situations comparative to management, which overvalued the nurses as being better prepared than they felt. The answers provided by the two categories of respondents for the second and third questions of the questionnaire are revealed below:

Novice nurse

Expert beginner

Advanced nurse

Proficient nurse

Capable nurse

Q2: How nurses see themselves

30 per cent

40 per cent

10 per cent

15 per cent

5 per cent

Q3: How management sees the nurses

5 per cent

7 per cent

60 per cent

15 per cent

13 per cent

An observation is made in that the beginning nurses tend to assess themselves as less capable, placing themselves mostly in the first and second categories of novice nurse and expert beginner nurse, whereas the managers tend to place the bulk of nurses in the advanced nurse category. In terms of proficient nurse and capable nurse, the differences between the perceptions of managers and those of nurses are decreased, as follows:

20 per cent of the nurses state that they are proficient or capable, whereas

Management sees that 28 per cent of the nursing staffs is capable or proficient.

While the discrepancy still exists at these stages too, it is lower and management and nurses seem to have a more aligned vision of the number of the proficient and capable staffs. Nevertheless, the massive differences in perceptions in regards to the three initial categories (novice nurse, expert beginner and advanced nurse) raise concerns within the elderly care institutions. The reasons for this difference in the views of management and nursing staffs could be explained through several ideas, for instance:

The nurses feel an increased pressure for their job; they also sense a fear that they might not be performing their jobs at the highest possible standards and they, therefore, tend to underestimate their skills and qualifications

The managers are less in touch with the actual operations developed by the nurses in caring for the elderly; they could be unaware of the complexity of their responsibilities and they could have higher expectations, which would be reflected in beliefs of skills higher than those assumed by the nurses themselves.

Ultimately, given this discrepancy, it will be necessary for the institutions to take additional measures to either adjust the perceptions to the reality of the situation, or to increase the training levels in order to ensure that the first two categories are better prepared to take on the roles of advanced nurses. Throughout the recommendation section, both propositions are discussed.

4.1.2. Sources of competencies

Questions three and four of the questionnaire were focused on the means in which the nursing competencies are developed. In other words, it was sought to reveal what the nurses and the managers believed constituted adequate mechanisms to create skills and competencies. The table below reveals the answers collected:

Education

Experience

Training

Others

Q3: Nurse perception

10

50

20

20

Q4: Management perception

70

10

10

10

Similar to the means in which nurses and managers classified the skills and competence levels of the nurses, in terms of the sources of these competencies differences also arise. And the most relevant such difference is observed at the level of education and experience as sources of competencies. In other words, nurses expect to complete their schools and get a diploma so that they can gain more of the necessary skills through actual clinical practice. The managers, on the other hand, expect the nurses to already have developed such skills and competencies during their educational processes. This discrepancy is a potential source of conflict within the workplace, especially since the nurses expect to be given opportunities to develop competencies and the managers expect them to already operate based on the necessary skills and competencies.

4.1.3. The required leadership competencies

The final set of questions in the questionnaire targeted the nurses and managers perceptions regarding the skills necessary to be employed and developed within the elderly care system of Gibraltar, and specifically, within their institutions.

Guidance from leaders

Mission and vision

Communications

Learning and development

Change management

Influencing others

Q5: Nurse perception

20

10

20

40

5

5

Q6: Manager perception

10

10

5

10

20

45

Similar to the first and second set of questions, the inquiry into the most important leadership competencies also shows discrepancies between staff and management perspectives. In this order of ideas, the competencies most important for the managers are the ability to influence others and the ability to guide and efficiently implement change, whereas for the staff members, the more important competencies are those of continuous learning and development, clear and transparent communications and a sustained guidance from leaders.

The findings from data collection from the questionnaire are hereby completed with a brief case study presenting the generally required leadership skills within the care organizations. These are as follows:

Transformation, execution and focus on people. This model was developed by the National Center for Healthcare Leadership and it includes competencies such as an orientation towards achievements and on the community, financial skills, innovative thinking, strategic orientation, accountability, communication skills, change leadership, impact and influences, project management, talent and self development, human resource management or professionalism and interpersonal understanding (National Center for Healthcare Leadership, 2010).

Different skills organised into five competency domains, as follows: (1) communication and relationship management, (2) professionalism of all teams, (3) leadership skills, (4) knowledge of the health care system and last (5) business skills and knowledge (Stefl, 2008).

Four model-based competencies: (1) well-cultivated self-awareness, through competencies such as loyalty and emotional intelligence; (2) a compelling vision, through competencies such as the development and communication; (3) a real way with people, through competencies such as listening or mentoring skills, and last (4) a masterful execution, through skills such as informal power, true consensus, decision making, creativity and adaptability - and the means to cultivate all these in the staff members as well as in leaders and managers (Dunn, 2014).

Currently, there has not yet been developed a specific framework for the required skills and competencies within the domain of care or elderly care, but each institution is encouraged to develop its own set of such competencies in order for them to best meet their pre-established objectives.

4.2. Data presentation and analysis from the management interviews

As it has been mentioned throughout the research methodology section, the interviews were conducted with 10 of the 20 managers in the elderly care system and they had been structured around six primary questions. Each of these questions is discussed below, based on the responses retrieved by the managers.

4.2.1. Interview question 1: What is your general opinion of the general situation in your institution, from a leadership competencies standpoint? From your point-of-view, what leadership competencies are required within your institution and how well are they met?

The interviewed managers from the three different institutions across Gibraltar gave very different depictions of their institution's leadership competence levels. The differences in responses indicate to two specific elements:

The competence of an institution is a matter intrinsic to itself, generated by the specific traits and features of the respective institution and it is understandable that managers from different companies give different answers, seeing as they describe the specifics of their own institutions. Secondly:

The differences in the answers offered by the managers are also different due to the fact that they are subjectively interpreted by each individual manager. In neither three of the companies had there been implemented mechanisms to assess the leadership competencies of the institution.

A third note which should be mentioned is that despite the differences in the answers given by the managers in the elderly care institutions, consistent similarities were offered by the managers employed within the same institution. In other words, while the assessments do carry the subjectivity of the managers, those managers working within the same institution pinpointed to the same categories of competencies, revealing as such some degree of homogeneity between the answers of the managers from the same institution and a heterogeneity regarding the answers of managers from different institutions.

The managers in the first institution, a designated elderly care facility in Gibraltar, argued that they sustained relatively high levels of leadership competence. That they were able to hire and retain quality staff members which provided quality care services to their patients. Within this facility, an organisational culture appeared to exist that centered around the well-being of the patients and high levels of patient satisfaction reflected high levels of leadership competence. In other words, this institution seemed to measure its leadership success through patient satisfaction. At this level, an important note to be made is that the company placed little emphasis on the leadership role of empowering its staff members, creating a vision for them and developing them.

The managers in the second elderly care institution of Gibraltar, also a designated facility, placed more emphasis on their staff members and assessed their leadership competences through the relationship they were trying to develop and maintain with their nurses. In other words, this institution sought to empower its nurses to continually develop their skills and competencies and to take on more responsibility in both patient care as well as operations management. The aim of this effort was that of increasing their involvement and commitment, to then generate higher quality services at the level of the entire institution. The actual support offered was however decreased and the retention level were also decreased, especially since the nurses often felt pressured into taking more responsibility even if they felt they were not prepared for such a measure.

Last, the third institution revealed the least interest in assessing and developing leadership competencies. Their standpoint was that of creating cost efficiencies and providing the minimum necessary care to its patients. The institution sought to reduce costs as much as it could and to create operational efficiencies. The institution was also understaffed and with the highest level of employee turnover - this was the hospital wing and it was being funded by a restricted budget.

4.2.2. Interview question 2: Do you currently have in place any systems to stimulate the participation of nurses in the managerial act?

The answer to this question was relatively unanimous across the twenty interviewed managers, in the meaning that they all stated that they did not have a specific plan in action to develop leadership competencies of their employees. The second institution nevertheless stated that they, in a semi-structured manner, sought to establish a relationship of equality between nurses and management and by this, to empower nurses to take on more responsibility and subsequently, develop leadership competencies. A carefully developed plan to build such competencies or the support for such an endeavor lacked.

4.2.3. Interview question 3: How would you describe the commitment of nurses to the performance of their care for the elderly?

The ten managers interviewed gave similar answers to this question, in the meaning that they all stated that the commitment of nurses to the care of the elderly is high, and that this is due not only to their high professional standards, but also to the nature of the work they perform. Managers as such confirmed the observation over the nurses that they do take it as personal responsibility the well-being of the elderly within their care and that they sometimes even get attached to the patients. In other words, there is the factor of human relationships and dependency which develops between the nurses and the patients and this motivates the nurses to increase their commitment and the performances of their care.

4.2.4. Interview question 4: Do you currently have in place any systems to assess the managerial performances of the nurses within your institution?

The managers in all three institutions stated that they were interested in evaluating the performances of their staff members and that they had in place some systems to assess these performances. One institution, for instance, assessed it through questionnaires handed out to patients by which they asked them to assess the quality of the services they were offered. The second institution stated that they conducted interviews with the staffs in order to assess how involved they were in improving their performances in terms of both care, as well as relationship with the management and the overall improvement of the services provided by the institution. The third institution stated that it was currently working on a plan by which to appraise the managerial performances of its staff members.

In all three situations then, there was an increased interest to assess the management performances of the employees, yet none of the institutions had a structured plan of how this assessment could be completed. The section on recommendation will reveal a proposed plan to assess this, but at this stage, it is important to note that the findings from the interviews with the managers are consistent with the findings in the wider context of nursing care, in which an appraisal plan is difficult to implement.

A brief case study

The case study approach is hereby employed to complete the data collected from the managers in the three elderly care institutions in Gibraltar and to show that there is indeed a difficulty across the entire sector in terms of assessing the performances of the staff members in nursing care. In this sense then, a first evidence is represented by a 2014 study by Nasrin Nikpeyma, Zhila Abed Saeedi, Eznollah Azargashb and Hamid Alavi Majd who assessed all care units in a large teaching hospital in Tehran and found out that they all lacked in proper assessment method. The causes for these shortages were multiple and varied from one unit to the other, but mostly included organizational context shortages, problems related to the performance appraisal structures or problems related to the performance appraisal processes and results.

In order to overcome these challenges, Needleman, Kurtzman and Kizer (2007) point out that it is necessary to involve and gain support from the totality of stakeholders of the nursing care system. Furthermore, Miler and Drake (1980) point out that flexibility is also important. In other words then, the available cases validate the difficulty in creating and implementing an appraisal system, yet they also reveal the need for it and the requirement for management to be consistent in creating such a nursing performance appraisal plan.

4.2.5. Interview question 5: How would you describe the employee turnover rate in your institution? Do you see this turnover rate as a problem?

As it was already expected from the previous research conducted, all three managers agreed that their institutions - as well as the entire elderly care sector - were facing a severe problem with high employee turnover. The perceptions of managers were more business oriented than those of the nurses, where a personal and emotional stance was more predominant.

The managers mentioned that they were a constant threat that their nurses and leaving and in a continuous search for new nurses to hire. The constant threat that nurses were leaving the elderly homes - and the constant materialization of this threat - destabilizes the institutions and makes it difficult for the managers to develop and implement plans, appraisals and other measures for control and improvement. It had often been the case that the new nurses had received extensive training within the institution and then they had left within the short period of time, costing the institution time and money and leaving it to search for other nurses.

One of the managers mentioned that they had considered asking their nurses to sign employment contracts by which they would agree to not leave the institution for at least two years, so that they could better protect the elderly home from such personnel fluctuations. Still, the institution did not implement such a measure as it considered that forcing the nurses to remain with the institution would reduce their motivation and job satisfaction, which were already low, and would damage the quality of the work performance. Additionally, the inclusion of such a legal clause would have also discouraged new nurses to seek employment within the respective institution.

The continuous search for nurses also poses a major threat to the institutions since managerial talent is constantly invested in searching for new members, meaning that their ability to improve the operations is decreased. Furthermore, alongside with a decreased ability to integrate all staffs within an organizational culture, the high employee turnover rate also generates additional costs for the institutions.

To address the problem of high turnover rate among the nurses, one of the managers said they had recently signed a partnership with a specialized recruiting agency who would recruit and send for interview potential nurses as often as this was possible. Another manager mentioned that they started looking at nurses from other countries, especially the less economically developed ones, in hopes of hiring them and motivating them through the salary.

4.2.6. Interview question 6: What leadership skills do you think are required to improve the overall performances within your institution?

Throughout the discussion so far conducted with the managers in the three elderly care institutions in Gibraltar, important similarities have been observed, such as high turnover rates for the nursing staffs or an increased emotional pressure for the staffs caring for the elderly. These challenges which were faced in all three institutions are generated by the specific traits of the sector of elderly care, and this feature explains the similarity in the challenges faced. But in terms of management and leadership competencies, the feedback from managers was different and based on the specifics of each institution.

In this order of ideas, the managers from the first institution mentioned that the leadership competencies most important for their elderly care facility was that of patient satisfaction, and therefore, they would be putting further emphasis on the skills and competencies which improve the quality of the services provided. They would therefore place more emphasis on professionalism, accountability and community orientation.

The managers in the second elderly care institution stated that their leadership emphasis remained on building strong relationships with the staffs and empowering them to take on more responsibilities and further develop the services and the quality of the operations. In terms of specific leadership competencies, they would be placing emphasis on human resource management, relationship building, talent development and team leadership. Last, the managers in the third institution believed that the most important skills were linked to operational efficiency and they would be placing emphasis on change leadership, information technology management and process management.

4.3. Findings from observations

4.3.1. Particular job challenges for the nurses

Through the direct interaction with the nurses, observation of their activities and direct non-structured discussions with them, an important element has been observed. Specifically, the domain of elderly care is highly demanding, both physically, as well as emotionally. Often times, the nurses deal with difficult patients, suffering not only from old age, but also from various illnesses, meaning that they require special care. The nurses often face refusal from patients when these are asked to take their medicine and the patients are also uncooperative in other instances as well. This problem is common with caring for the elderly and recurrent issues with which the nurses are faced include:

Refusal to take their medicine or respect a hygiene routine

Refusal of help and lack of cooperation; the elderly often try to fire the nurses from their care, yet this is more common in home care rather than in institutions (all three institutions hereby assessed only provide care within their institutions)

Constant complaining about the food, the water, the beds, the people, the medicine and everything else, despite the intense efforts of the nursing staff

Agitation, anger and even verbal aggression; on rare occasions, even violent behavior

Refusal to participate in social interactions and activities organized by the care facilities

Disorganization, forgetting things, losing them, paranoia, calling the police to complain that their neighbor is stealing their belongings (Website of Helping You Care).

The nurses have the mental and the technical skills to handle such situations and they know that the elderly require additional attention due to multiple challenges them themselves encounter as a result to old age and poor health - a reduction of their physical and even mental capacity, increased dependence on other people or depression. In other words, the nurses are professionals who understand the complexity of the problems their patients face and they do not take their opposition personally. Yet, in spite of all their training, the nurses are also vulnerable human beings and their emotional balance is negatively affected by the challenges of the job. And these challenges are numerous.

An observation: during the visits in one of the three elderly care institutions assessed, one of the residents had passed away and the nurse that had been on shift was extremely distraught by the event. The man was an 86-year-old male, who had been an easy and pleasant patient and who often cheered up the staffs and the other residents in the care institution. The nurses in the elderly care system, aside from facing the challenges of caring for the elderly, are also faced with high rates of death, and this affects their emotional state.

4.3.2. High turnover rate

During the visits within the three elderly care institutions - two designated and one integrated within a hospital - another important observation was made in that during the period of the research at least five nurses quit their jobs. The reasons as to which these nurses quit their jobs differed from one instance to the other, but the common element was that the current job was raising too many difficulties for them. One nurse left the elderly care unit to work as a nurse in a daycare program for children; two nurses left because they found new jobs within health care institutions (one in a hospital and one in a private clinic). The fourth left because she requested an early retirement and the fifth because she felt close to a nervous breakdown and needed some time for herself.

Regardless of the actual reason as to why they leave, this phenomenon is highly intense among elderly care nurses and it is linked to the significant complexities of the job, such as the high level of emotional investment, the constant proximity to death or the difficulties in caring for the ill elderly. The phenomenon was confirmed by various nurses, who stated that they are often driven into the sector due to their personal desires to help, or simply because they see caring for the elderly as a regular nursing job, but they are often overwhelmed by the particular challenges raised by the sector. One of the nurses said:

"I have been working here for three years now and I am one of the veterans. There are only 2 other nurses who have been working here for longer than that. Sometimes new nurses come in and leave after just a few days. It's hard for them, and it's also hard for us."

By further discussing with the nurses and observing the situation, another important point was raised, namely that the high rate of nurses leaving forces management to continually replace the staffs. And while this is an aspect which will further on be discussed during the interviews with managers, it is important to note that while new nurses are being sought and hired, the workloads for the current nurses increases, to further add to the stress and pressures of elderly care in the institutions in Gibraltar.

4.3.1. A brief case study: nurse turnover

Aside from the personal perception of the difficulties posed by the elderly care system which often constitutes the reason as to why nurses leave the profession, an organizational factor is also important to observe, namely the fact that this situation leads to high employee turnover rates. This issue is further on addressed through a brief case study.

A 2013 study of staff turnover in american senior facilities dedicated to assisted living revealed a 24.2% of turnover among the adjacent staff. This figure was an improvement comparative to 2012 and it had constituted of all staffs in the respective facilities, including directors, marketing staffs, nurses, dieticians and housekeeping personnel. Among these categories however, the turnover rate for the registered nurses had been the highest at 36.4 per cent in 2013, down from 50.0 per cent in 2012 (The National Center for Assisted Living, 2015). In some institutions, the rate of nurse turnover rate is up to 100%, and it remains high, despite efforts aimed to reduce it (Mukamel, Spector, Limcangco, Wang, Feng and Mor, 2009).

Turnover rate is common in all institutions and a low employee turnover rate is beneficial to ensure that the employees who do agree with the organizational culture can leave and those who stay are integrated within the organizational culture. Nevertheless, a high unemployment rate is disruptive for the institution. Studies conducted in the field to assess the reasons for the high nurse turnover rates have revealed distinctive findings, based on the sample they had considered in their study. Some examples of reasons associated with high turnover rates among nurses include: increased workload, low levels of staffing, low wages, poor benefits, ineffective communications, poor supervision, poor retention plans within the institutions or even factors such as the general employment rates within the society. In other words, the high turnover rate among nurses in care facilities is difficult to assign to a specific factor, since it seems to be present across the world and with varying reasons behind it. "The large number of factors associated with turnover on the one hand, and the inconsistency in findings across studies on the other, suggest that turnover is a complex phenomenon, which may not be easily amenable to policy interventions" (Mukamel, Spector, Limcangco, Wang, Feng and Mor, 2009).

4.4. Discussion of practical recommendations from the research

The current stage of the project assess the findings retrieved through each of the specific research methods and provides propositions as to how the identified issues could be approached. Throughout the final section of the project, the recommendations will be centralized and restructured in order for them to address the four initially raised study objectives.

4.4.1. Recommendations based on the questionnaire

In terms of the competencies and skill levels assigned by the nurses themselves and the managers, a discrepancy is observed in the meaning that the nurses see themselves as less prepared than the managers. In other words, the managers seem to believe that their staffs are better able to handle everyday and managerial responsibilities than the staffs actually think of themselves. In order to address this issue, two recommendations are made: the creation of an internal system to classify nurse competencies and secondly, the creation of a development plan to improve nurse competencies.

First of all, the creation of a clear internal system should define and assesses the skills and qualifications of the nurses at of the following five levels:

Novice nurse

Expert beginner nurse

Advanced nurse

Capable nurse and Proficient nurse.

The competencies required at each of these levels as well as the responsibilities assigned to each nurse level would be developed internally, based on the specific needs and resources of each elderly care institution in Gibraltar. An example in this sense could however be represented by Patricia Benner's classification system, which could be adapted to meet institution specific needs.

Type of nurse

Level characteristics

Novice nurse

Has no experience

Lacks confidence to perform safe practices

Requires continuous cues

Needs prolonged practice

Is unable to use discretionary judgement

Advanced beginner

Has previous experience

Marginally acceptable performances

Developing knowledge

Partially skilled

Requires occasional cues

Competent

Similar job experience for 2 or 3 years

Is efficient, coordinated and confident in their actions

Approaches problems based on plans, which are conscious, abstract and analytical

Does not require supportive cues

Proficient

Perceives situations in an integrated manner

Assess the long-term implications of situations

Creates comprehensive plans and is able to modify them

Possesses vast experience

Holistic approach and improved decision making

Is less laboured because they can better prioritize

The expert

Has an intuitive grasp of the problematic situation and acts on it specifically, disconsidering inefficient approaches

Has a deep understanding of the total situation

Highly skilled, experienced and analytical (NSW Government, 2011)

While the elderly care institutions should develop their own internal systems to classify the skills and competencies of their nurses, what is important that they all do is to make this classification plan, clear, and as available to nurses as possible. Such a measure will ensure a reduction in the discrepancies perceived by nurses and managers in terms of nurse competencies and a more accurate starting point in the provision and long-term quality of elderly care within the institutions in Gibraltar.

4.4.2 Recommendations based on management interview

4.4.2.1. Assessing leadership competencies

None of the three elderly care institutions had put in place a specific method of assessing their leadership competencies. The first institution linked its leadership competencies to the satisfaction of its patients and their families. The second institution linked it to its efforts towards sustaining a positive relationship with its staff members. The third institution had the lowest interest and involvement towards assessing and developing leadership competence and their view was focused on creating operational and managerial efficiencies. The first two institutions mentioned that their levels of leadership competency were satisfactory, whereas the third mentioned they faced severe cost challenges in this sector. In such a setting then, the practical recommendations are based on the specific situation of each of the three institutions.

As such, in the case of the first institution, the recommendation is that of focusing more on the staff members too, alongside with the level of patient satisfaction. The level of patient satisfaction is directly linked with the quality of the care they receive, and the quality of this care is directly linked with the satisfaction of the staff members. In other words, satisfied nurses will deliver high quality services to also generate high levels of patient satisfaction, whereas nurses who are unsatisfied in the workplace will deliver lower levels of care, which will then negatively affect the quality of patient satisfaction. In such a context then, it is recommended for the leaders and managers at the first elderly care institution to develop leadership skills at the level of their employees. Some examples in this sense could include:

Creating a favorable working environment

Supporting the personal and professional advancement of the staff members

Encouraging them to take on more responsibility

Rewarding and celebrating the staff members when they attain extraordinary achievements.

In the instance of the second institution, which focuses on employee relationships, the recommendation is that of providing them with more support. The employees which are better supported by management will better attain their career objectives, rather than those who are under management pressure to improve their working habits, yet they do not receive any support in the endeavor. Aside from working with the employees, this institution is also recommended to develop other means of improving its leadership competencies, as this will be discussed throughout the following sections.

Finally, the third institution, is recommended to focus on the efficiency of its operations, but also to seek to develop other approaches to developing leadership competencies. Still, in the case of this institution, challenges are faced with cost and personnel resources, and leadership competencies are not seen as a priority. Nevertheless, the actual development of leadership competencies could be a positive solution for the institution in further improving its operations and its efficiency in utilizing resources. While the two previous institutions could rely on their internal management teams to develop the suggested improvements in leadership competencies, the third institution is suggested to work with a specialized consultant throughout this process, due to the complexity of its challenges.

Developing leadership competencies

At the level of the three institutions, an integrated recommendation is made in the development and implementation of a leadership assessment plan. In other words, the institutions should define what successful leadership means for them and how this should be presented within the real life context and then assess the means in which their institution is able to attain the respective leadership criteria. Such an assessment plan would be developed internally by each individual institution, based on its objectives, resources and other particular aspects - it has already been mentioned that the institutions value different aspects of their operations and the assessments plan would be created to reflect these individual preferences. Nevertheless, a good starting point in the creation of a leadership competencies assessment plan comprises of the following suggestions:

Analyzing the level of employee satisfaction on the job (a higher level of satisfaction often reflects higher leadership competencies)

Assessing the relationships and interactions between the staff members, since positive working environments are also indicators of good leadership competencies

Assessing the efficiency of the operations

Assessing the means in which the resources of the institution are utilized to create the best possible advantages (such an analysis would be completed by the financial department by comparing the means in which the resources are utilized)

Assessing the quality of the services through not only patient and family satisfaction, but also through an assessment of the levels of patient safety or adjacent services provided

Assessing the vision and mission of the institution, if this exists, or otherwise, creating and enforcing such a mission and vision to integrate all institutional efforts under the same umbrella of positive actions and intentions

4.4.2.2. Appraisal system

An important finding of the research conducted so far is that the elderly care institutions are interested in an appraisal system by which to assess the managerial performances of their staff members, yet they have yet to develop and implement such a system. Therefore, the recommendation at this point is that of creating a better appraisal system, based on the following specific recommendations:

The identification of job specific requirements and standards to be met, in terms of both nursing and technical knowledge, as well as managerial knowledge and activity

The clear communication of these standards and expectation to the nurses, in an effort for efficient and transparent communication

The provision of support for the nurses to comply with these new requirements and standards. This support could come in the form of group trainings, as well as individual consultations with each nurse in order to identify their personal shortages and emphasize on resolving them

The creation of a strong and clear internal structure which informs the nurses where to find help and guidance in case they need it for every day-to-day operations, situations in which they do not know how to address a specific patient grievance or situations in which they feel overwhelmed and they need support

The improvement of the entire infrastructure within the elderly care in order to support more efficient operations and a higher quality of the nursing act; this, for instance, could refer to better equipments necessary in elderly care or better reporting systems between nurses and even with the management.

4.4.3. Recommendations based on observations

4.4.3.1. Emotional state of nurses

Aside from the creation of a structured system of employee appraisal, another important recommendation is that of developing the emotional state of the nurses. As it has already been mentioned, the nurses are trained professionals, yet they are often affected by the particular challenges of caring for the elderly, and this often translates into high employee turnover rates.

In order to address this cascading challenge, the managers of the elderly care institutions in Gibraltar could develop new efforts to improve the emotional stability of the nursing personnel. This could be attained through specific efforts which make the job easier, such as more flexible hours, increasing the number of staffs to reduce the workload per staff member, the use of technology to make various operations more efficient and so on. Additionally, it is recommended for the management of the institutions to provide specialized assistance on a permanent basis for the nurses in order to increase their resilience and emotional stability.

4.4.3.2. Increase nurse retention

The high levels of nurse turnover rates pose a significant threat for the stability and performances of the elderly care institutions in Gibraltar. Therefore, a recommendation is made at this state to improve the levels of nurse retention within the respective institutions. In order to attain this objective, the following processes are promoted:

The creation of a working climate that is as pleasant as possible for the nurses

This might be a challenging effort given the nature of the processes nurses complete on daily basis and their high commitment to the job, but few added details could improve the general working environment, such as offering the nurses free coffee and refreshments during the day, organizing social gatherings outside the workplace so that the nurses can interact, get to know each other better and form trustworthy relationships.

The creation of flexible working hours

Such a measure would improve the morale of the nurses by better allowing them to balance work and personal life. For instance, nurses who have young children would be able to create their working hours around the schedule of the child. This measure would not only increase the satisfaction and retention of the already hired nurses, but, through word of mouth, would also constitute reasons for potential nurses to apply for jobs within the institutions.

The implementation of flexible working schedules is a measure adequate for the managerial team since it does not generate additional costs, but it does manage to create important benefits in employee satisfaction and retention. The necessary requirement for this process to adequately function however is represented by the constant supervision of the working schedules and the reliance on the responsibility of the nurses.

The encouragement and reward of the loyal nurses

This measure virtually refers to the creation of special packages and facilities for nurses who had been employed within the same institution for a prolonged period of time. The actual period of time upon which additional benefits are offered would be offered differently within each organisation, based on their resources and scopes, but a minimum period of two years is recommended.