Management Performance and Leadership in Gibraltar Elderly Care

Introduction and Background

The elderly nursing community in Gibraltar is dispersed and characterized by institution-specific challenges and particularities. This project assesses the general level of leadership competencies within three pre-selected institutions, examines the management performance evaluations of employees, identifies the basic leadership skills required, and formulates a series of recommendations for how these competencies could be developed. The approach is predominantly qualitative, combining various research methods — including questionnaires, case studies, and structured interviews.

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

Much emphasis has been placed on the health care system in recent years due to the numerous changes and pressures faced by the sector, including inequities in the globalized world, ecological, demographic, 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 of adequate care management practices, particularly due to their ability to reduce inequalities, increase access to medical care, and promote quality and safe care.

The training of nurses 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). A nurse or professional demonstrates competence when effectively applying 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 with the technical and managerial skills to organize, monitor, evaluate, and promote improvements in the quality of nursing care. In this sense, the concept of Care Management — as the stable union of management and care — arises as something greater than the sum of its parts (Wilson, 2015).

For the proper management of nursing care, implementation of management actions and nursing administration is required. In nursing homes for the elderly, performance management is important for organizing care through the allocation of sufficient resources. However, this alone is not sufficient — 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 because it indicates how best to organize resources in order to provide humane care.

Problem Statement

Leadership is defined as the process or art of influencing people to voluntarily strive toward achieving the objectives of a group. It encompasses the knowledge, skills, and abilities that allow a leader to direct those around them through effective and strategic collaboration, negotiation skills, oral and written communication, and team motivation and decision-making (Reid & Weller, 2010). As part of leadership skills and teamwork, it is expected that nurses communicate in a style consistent with appropriate values that support the health system and the nursing workforce, and that reflect a healthy work environment (Reid & Weller, 2010).

Management skills and leadership are recognized as essential components of practice — not only for nurses, but for all health professionals — and their development will enable 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 better understand and serve the patient. Germain and Cummings (2010) demonstrate in their research that nursing leadership style has an impact on nursing performance. Factors that nurses perceived as motivators for good performance include autonomous practice, positive labor relations, access to resources, individual characteristics of nursing, and effective 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 care homes in Gibraltar is a demanding task requiring leadership, training, and management skills. Nursing home management performance requires that these institutions be led with multiple competencies and skills.

Purpose of the Study

The purpose of the current study is to explore and understand the management performance of nursing homes for the elderly in Gibraltar. The scope is to reveal how these nursing homes are managed through the use of the most appropriate leadership competencies and to answer four specific research questions that support the further development and improvement of elderly care in Gibraltar.

A secondary purpose is to add to the current body of literature on the characteristics of elderly care in general and in Gibraltar in particular. This specific topic is only limitedly addressed in the existing literature, meaning that the current project will contribute useful data on the subject and promote further research in the field.

Research Objectives

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

First, to assess the general situation of nursing homes for the elderly in Gibraltar from a leadership competencies perspective. Second, to explore the assessment of management performance of employees in nursing homes for the elderly in Gibraltar. Third, to evaluate the basic leadership competencies required to manage nursing homes for the elderly in Gibraltar. Fourth, to recommend competencies and leadership skills that will help to better manage nursing homes for the elderly in Gibraltar.

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

Literature Review

Introduction to the Literature Review

The literature review section serves as the starting point of the research process, completing a thorough analysis of available literature on nurse care, elderly care, nursing appraisal systems, and other related topics. A limitation of this section is that it presents general data from available sources without direct reference to evaluating management performance within the elderly care facilities in Gibraltar specifically. Nevertheless, the specific issues are addressed further through primary and secondary research, and the literature review represents the general theoretical context against which the study is set.

Review of Nursing Qualifications

The increased severity of patient conditions, decreased hospitalization times, and the proliferation of care technologies have increased the need for nurses with specific skills that enable them to adapt to these changes. Studies that analyze nursing competencies as essential to ensuring safe, quality health care affirm that these competencies 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 (beginner), an advanced beginner nurse, a competent nurse, a proficient nurse, and an expert nurse. The novice nurse demonstrates competence by implementing tasks through knowledge of attributes that do not require prior experience — tasks requiring only theoretical knowledge for execution. The advanced beginner demonstrates an acceptable performance level and can perform more complex tasks where at least a minimum level of prior experience is required. At these levels, nurses need support in clinical performance and help establishing priorities, as they are not yet able to identify what is most important.

The competent nurse has two to three years of experience, is able to see their actions in terms of long-term goals, and contemplates problems in an abstract and analytical way. Their practice is based on flexible responses produced by changes in patient needs. The competent nurse is able to make conscious and deliberate plans that achieve a level of efficiency and organization in their work, coordinate complex demands, and make sound decisions (Benner, 1982). The proficient nurse perceives situations holistically rather than as a series of tasks, which improves decision-making ability.

The expert nurse represents the highest level of development; they possess an intuitive and profound understanding of situations due to enormous experience and adaptability. The performance of the expert nurse is integral rather than procedurally fragmented, and there is a link between clinical and ethical reasoning (Benner, 1982).

Review of Leadership and Managerial Competencies

In the study by Tabari et al. (2007) on the development of skills in nursing, the authors conclude that this is a highly integrated, constant interaction process in which the nurse plays the primary role. This process is called "the process of constant interaction" and has five main phases: (1) recognition of the driving force that motivates nurses toward the development of competence; (2) provision of appropriate requirements, sufficient theoretical knowledge, and support to meet minimum requirements for participation; (3) experience at the heart of the development process, providing an opportunity to link theory with practice; (4) consolidation through complete mastery of the proposed work via repeated practice and reflective coping; and (5) integration of new skills with the old, preparing the nurse to teach and supervise in related areas.

The authors note that these stages are interconnected rather than chronologically ordered, and that a nurse may experience different stages simultaneously in different roles. Mowinski (2007) conducted a literature review that found leadership competencies were addressed almost twice as often as management competencies, despite their similarity in practice. Of the top ten competencies common to nursing home management and leadership, the following were identified: interpersonal skills, critical thinking, communication, management skills (planning and organization), business skills (finance and marketing), change management, and health knowledge and health care. Of these ten, only two were identified as exclusively leadership-oriented — setting a vision and developing people — while only two were identified as exclusive to management: human resource management and information management.

Cummings et al. (2010) conducted a systematic review that included ten databases and 34,666 items, exploring the relationships between various leadership styles and outcomes for nurses and their work environments. They found that leadership styles focusing on people and relationships — such as transformational, resonant, and supportive leadership — are associated with greater job satisfaction among nurses. Managerial tools associated with higher staff satisfaction included planning, service management, coordination, teamwork, negotiation, managing supplies, supervision, training, and recruitment.

Nurse Competencies

Several studies have established the skills to be developed by nurses, among which are leadership competencies such as communication, teamwork, and motivation, and managerial competencies such as delegation and supervision (Reid & Dennison, 2011; Supamanee et al., 2011). Research has also sought to identify factors associated with the effectiveness of nurse executives, finding significant relationships between success and attributes such as collaboration in multidisciplinary teams, business skills, people management skills, the provision of adequate tools and resources to nurses, nursing knowledge, quality management, and project management (Kirk, 2009).

The nurse, in the course of work performance, uses clinical judgment in the provision of services to enable people to improve, maintain, or regain their health. Nursing is an intellectual, physical, emotional, and moral process that includes identifying nursing needs, providing therapeutic interventions and personal care, delivering information, education, counselling, and supporting physical, emotional, and spiritual well-being. In addition to direct patient care, nursing practice encompasses management, teaching, policy, and knowledge development (Royal College of Nursing, 2003).

Regarding the importance of management and leadership in nursing, Meretoja (2004) recognizes seven categories of competencies in a nurse-based model. These categories were validated by a literature review and six expert groups. A scale of nursing competencies with very strong validity was built, and among the seven categories, administrative functions appeared in the second-highest frequency of use, after the helping role (Meretoja & Koponen, 2012; Meretoja et al., 2004).

Organizational Appraisal of Nursing Competencies

The specialized literature on assessing the performance of nurses is unanimous in recognizing an increased need to create adequate, well-structured systems that identify and evaluate nurse performance across various care institutions. The topic is highly complex, and despite widespread acceptance of this need, actual development and implementation of such systems remain tedious processes. Nikpeyma, Saeedi, Azargashb, and Majd (2014), for instance, assessed the appraisal system within a large teaching hospital in Tehran and found a multitude of problems preventing the implementation of an adequate appraisal system. These included:

Contextual problems, such as a disharmony between nurses' duties and the standards imposed on them, inadequate motivation, or organizational shortages — including equipment shortages — that prevent nurses from efficiently completing their responsibilities. Problems related to the structure of the appraisal system, such as subjectivity of appraisals, inefficiency in organizational laws and regulations, and a significant gap between required clinical practice and the actual theoretical training received. Problems related to the processes of performance appraisals, such as insufficient supervision from managers, unfair and subjective appraisals, and discontinuities in appraisal efforts. Finally, challenges related to the results of nurse performance appraisal efforts, including situations in which appraisals were conducted by inadequate personnel or were based on unreliable feedback (Nikpeyma, Saeedi, Azargashb, and Majd, 2014).

Despite these challenges, care facilities across the world are still encouraged to develop their own appraisal systems that best respond to their specific needs. Needleman, Kurtzman, and Kizer (2007) argue that the importance of appraisal systems rests on the fact that the quality of nursing directly influences patient safety, the general quality of health care provided, patient outcomes, and the working environment among nursing staffs. They recommend the strengthening and improvement of such systems at all levels, through consistent development of working procedures, standards, and infrastructure.

Summary of the Literature Review

An important component in the assessment of managerial performances in elderly care is represented by an evaluation of the skills and knowledge possessed by nurses attending to elderly patients and residents. Five specific categories of nurses were identified: a novice nurse, an expert novice nurse, an advanced nurse, a proficient nurse, and a capable nurse (Benner, 1982). These categories are distinguished by clear differences in assigned responsibilities, prior knowledge and expertise, and managerial expectations.

In terms of managerial and leadership assessment, the literature points to several discussions distinguishing between management and leadership, with leadership characterized by setting a vision and developing people, and management distinguished by a role in managing information and human resources (Mowinski, 2007). A common issue with appraisals and competencies is the absence of a universally accepted model, with multiple competing propositions existing within the general and specialized literature.

The literature presented here is sufficiently representative to serve as a theoretical starting point for the analysis and evaluation of elderly care in Gibraltar. However, the literary sources on the matter do reveal a shortcoming in that they tend to focus on the objective aspects of care from the perspectives of managers and nurses, without considering that the quality of care services could also be influenced by patients themselves (Sidani and Epstein, 2003).

Research Methodology

The Research Method

The research methodology is directly linked to the nature of the research objectives — it was developed to best collect the information required to answer the research questions. To assess leadership competencies in elderly care, evaluate staff, identify required competencies, and formulate recommendations, the study employs a combination of qualitative and quantitative research methods, collecting data from both primary and secondary sources.

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

Within the health care community, research is often conducted with the triangulation method due to these advantages. Speziale, Streubert, 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 include interviews with employees in the elderly care system in Gibraltar, observation of various situations within the institutions, and collection of data from secondary sources. The case study is also employed as a popular and useful research tool, offering deeper contextual analysis and the possibility to identify relationships between various factors relevant to the research (Soy, 2006). Secondary data is collected from reports, journal articles, and technical papers. The quantitative methods include questionnaires specifically developed for the study and processed through content analysis.

Sampling

The choice of employees for sampling is based on their direct daily exposure to care home performance. Data collection comprises questionnaires and semi-structured interviews, conducted both on a section-by-section basis and on a one-to-one basis where necessary, to gather first-hand information on employee experiences under the current management system. Sampling was undertaken using a stratified random sampling approach to ensure employees were accurately represented across age groups and levels of job responsibility.

The actual sample is composed of 100 individuals working within the elderly care system in Gibraltar: 80 respondents are employed in nursing care and 20 are managers. All respondents willingly and anonymously answered the questions. The respondents are employed in three different elderly care institutions in Gibraltar — two independent dedicated care homes for the elderly, and one specialized wing within a hospital dedicated to elderly care.

Of the 100 respondents, 85 per cent were female and 15 per cent were male. The majority of nurses were female, with some male nurses helping with more physically demanding responsibilities. In terms of age structure, more than half of the nurses interviewed were young or middle-aged. It was later observed that there is a high burnout rate among the nurses and that some request early retirement.

Analysis Technique

Once data from interviews, questionnaires, and an extensive review of the literature was generated, the next stage was the analysis of this data. Qualitative data was organized, analyzed, and interpreted to generate information within the established theoretical framework. The primary data collected was analyzed using content analysis. The research process maintains reliability by ensuring the accuracy of research techniques and procedures. Validity is checked by analyzing how well the research achieves its goals. Generalizability is maintained by considering how broadly findings can be applied. Ethical measures were applied through the use of consent forms for each participant, confirming voluntary participation without any pressure.

The Questionnaire

The questionnaire is an important and highly popular research tool due to the multitude of benefits it offers. Within the current context, it is used to collect data from both nurses and managers in order to easily retrieve necessary feedback from two distinct sources. The questionnaire also creates quantitative data useful for a more structured assessment of the problem. Results can be processed and interpreted in the context of the assessed situation, as well as compared to the available literature.

The questionnaire was administered to 100 respondents, all employed in the elderly care system in Gibraltar. Respondents voluntarily and anonymously answered the questions. The questionnaire is composed of ten questions, including the following key items:

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) Novice nurse; (b) Expert beginner nurse; (c) Advanced nurse; (d) Proficient nurse; (e) Capable nurse.

Question 3: How would you, as a manager, describe the competencies of your nursing staff (in percentages): Novice nurse / Expert beginner nurse / Advanced nurse / Proficient nurse / Capable nurse.

Question 4: How do you, as a nurse, develop your competencies for the job: (a) Through education and an adequate degree; (b) Through clinical experience; (c) Through training programs; (d) Through other measures.

Question 5: How do you, as a manager, believe that nurse competencies are developed: (a) Through education and 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 most important in your institution: (a) Guidance from 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 most important in your institution: (a) Guidance from leaders; (b) A leadership vision and mission; (c) Efficient and transparent communications; (d) Continuous learning and development; (e) Managing change effectively; (f) Influencing others.

The Interview Questions

The interviews conducted with managers in the three elderly care facilities in Gibraltar were structured around six questions, and each interview lasted approximately half an hour. Where necessary, additional questions were posed for clarification. The scope of the interviews was to gather primary data from managers in a semi-structured manner that allowed them to discuss openly what was of importance within their institutions.

While the questionnaires were completed by all targeted respondents, only 10 of the 20 managers were able to attend the discussions. This is explained by the fact that managers are frequently overloaded and unavailable. Nevertheless, the answers from ten managers are sufficient, as their responses reflect the general situation within the entire elderly care sector in Gibraltar.

The structured interview questions for managers were as follows: (1) What is your general opinion of the leadership competencies situation in your institution, and how well are they met? (2) Do you currently have systems in place to stimulate nurse participation in the managerial act? (3) How would you describe the commitment of nurses to the care of the elderly? (4) Do you currently have systems in place to assess the managerial performances of nurses? (5) How would you describe the employee turnover rate in your institution, and do you see this as a problem? (6) What leadership skills do you think are required to improve overall performance within your institution?

References

Arras, J.D. (1995). Bringing the hospital home. Baltimore: Johns Hopkins University.

Barker, A.M., Sullivan, D.T., & Emery, M.J. (2006). Leadership competencies for clinical managers: The Renaissance of transformational leadership. Jones & Bartlett Learning.

Benner, P. (1982). Novice to expert. American Journal of Nursing, 82(3), 402–407.

Booyens, S.W. (1998). Dimensions of nursing management. Juta and Company.

Brewerton, P., & Millward, L. (2001). Organizational research methods. Sage Publications.

Burns, L., Bradley, E., & Weiner, B. (2011). Shortell and Kaluzny's healthcare management: Organization design and behavior (6th ed.). Cengage Learning.

Calhoun, J.G., Dollett, L., Wainio, J.A., Griffith, J.R., & Warden, G.L. (2008). Development of an inter-professional competency model for healthcare leadership. Journal of Healthcare Management, 53(6), 375–389.

Cathcart, E.B., Greenspan, M., & Quin, M. (2010). The making of a nurse manager: The role of experiential learning in leadership. Journal of Nursing Management, 18(4), 440–447.

Cummings, G.G., MacGregor, T., Davey, M., Lee, H., Wong, C.A., & Lo, E. (2010). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 47(3), 363–385.

Dunn, L. (2014). 16 critical competencies for healthcare leaders. Becker's Hospital Review.

Germain, P.B., & Cummings, G.G. (2010). The influence of nursing leadership on nurse performance: A systematic literature review. Journal of Nursing Management, 18(4), 425–439.

Kirk, H. (2009). Factors identified by nurse executive directors as important to their success. Journal of Nursing Management, 17(8), 956–964.

Mercado, L. (2012). Strategies for nurse retention. Advanced Healthcare Network.

Meretoja, R., Isoaho, H., & Leino-Kilpi, H. (2004). Nurse Competence Scale: Development and psychometric testing. Journal of Advanced Nursing, 47(2), 124–133.

Meretoja, R., & Koponen, L. (2012). A systematic model to compare nurses' optimal and actual competencies in the clinical setting. Journal of Advanced Nursing, 68(2), 414–422.

Miler, R., & Drake, M. (1980). Standards of nursing performance: Tools for assuring quality care. Quality Review Bulletin, 6(5), 16–19.

Moiden, N. (2003). Leadership and the elder care home sector. Trafford Publishing.

Mowinski, B., Scalzi, C., Rodgers, J., & Keane, A. (2007). Differentiating nursing leadership and management competencies. Nursing Outlook, 55(4), 169–175.

Mukamel, D.B., Spector, W.D., Limcangco, R., Wang, Y., Feng, Z., & Mor, V. (2009). The costs of turnover in nursing homes. Medical Care, 47(10), 1039–1045.

National Center for Assisted Living. (2015). Findings from the NCAL 2013 assisted living staff vacancy, retention and turnover survey.

National Center for Healthcare Leadership. (2010). Health leadership competency model.

Needleman, J., Kurtzman, E.T., & Kizer, K.W. (2007). Performance measurement of nursing care: State of the science and the current consensus. Medical Care Research and Review, 64(2).

Newman, I., & Benz, C.R. (1998). Qualitative-quantitative research methodology: Exploring the interactive continuum. SIU Press.

Nikpeyma, N., Saeedi, Z.A., Azargashb, E., & Majd, H.A. (2014). Problems of clinical nurse performance appraisal system: A qualitative study. Asian Nursing Research, 8(1), 15–22.

NSW Government. (2011). Benner's five stages of clinical competence.

Reid, K.B., & Dennison, P. (2011). The Clinical Nurse Leader (CNL): Point of care safety clinician. Journal of Issues in Nursing, 16(3), 4.

Reid, U.V., & Weller, B. (2010). Nursing human resources planning and management competencies. International Council of Nurses.

Royal College of Nursing. (2003). Defining nursing. London: Royal College of Nursing.

Sidani, S., & Epstein, D.R. (2003). Enhancing the evaluation of nursing care effectiveness. Canadian Journal of Nursing Research, 35(3), 26–38.

Society for Human Resource Management. (2008). Leadership competencies.

Soy, S.K. (2006). The case study as a research method. University of Texas at Austin.

Speziale, H.S., Streubert, H.J., & Carpenter, D.R. (2011). Qualitative research in nursing: Advancing the humanistic imperative. Lippincott Williams & Wilkins.

Stefl, M.E. (2008). Common competencies for all healthcare managers: The Healthcare Leadership Alliance model. Journal of Healthcare Management, 53(6), 360–373.

Supamanee, T., Krairiksh, M., Singhakhumfu, L., & Turale, S. (2011). Preliminary clinical nursing leadership competency model: A qualitative study from Thailand. Nursing & Health Sciences, 13(4), 433–439.

Tabari, R., Kiger, A., & Parsa, A.F. (2007). Competence development among nurses: The process of constant interaction. Journal of Continuing Education in Nursing, 38(5), 211–218.

Website of the Central Intelligence Agency. (2015). The world factbook. https://www.cia.gov/library/publications/the-world-factbook/fields/2010.html

Wilson, Simmons, III. (2015). Caring for parents and other loved ones. BookBaby.

Wong, C.A., & Cummings, G.G. (2007). The relationship between nursing leadership and patient outcomes: A systematic review. Journal of Nursing Management, 15(5), 508–521.