The Responsive Leadership Intervention: Improving leadership and individualized care in long-term care

Collective leadership to improve professional practice, healthcare outcomes and staff well-being

BACKGROUND

Collective leadership is strongly advocated by international stakeholders as a key approach for health service delivery, as a response to increasingly complex forms of organisation defined by rapid changes in health technology, professionalisation and growing specialisation. Inadequate leadership weakens health systems and can contribute to adverse events, including refusal to prioritise and implement safety recommendations consistently, and resistance to addressing staff burnout. Globally, increases in life expectancy and the number of people living with multiple long-term conditions contribute to greater complexity of healthcare systems. Such a complex environment requires the contribution and leadership of multiple professionals sharing viewpoints and knowledge.  OBJECTIVES: To assess the effects of collective leadership for healthcare providers on professional practice, healthcare outcomes and staff well-being, when compared with usual centralised leadership approaches.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 5 January 2021. We also searched grey literature, checked references for additional citations and contacted study authors to identify additional studies. We did not apply any limits on language.

SELECTION CRITERIA

Two groups of two authors independently reviewed, screened and selected studies for inclusion; the principal author was part of both groups to ensure consistency. We included randomised controlled trials (RCTs) that compared collective leadership interventions with usual centralised leadership or no intervention.

DATA COLLECTION AND ANALYSIS

Three groups of two authors independently extracted data from the included studies and evaluated study quality; the principal author took part in all groups. We followed standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We identified three randomised trials for inclusion in our synthesis. All studies were conducted in acute care inpatient settings; the country settings were Canada, Iran and the USA. A total of 955 participants were included across all the studies. There was considerable variation in participants, interventions and measures for quantifying outcomes. We were only able to complete a meta-analysis for one outcome (leadership) and completed a narrative synthesis for other outcomes. We judged all studies as having an unclear risk of bias overall. Collective leadership interventions probably improve leadership (3 RCTs, 955 participants). Collective leadership may improve team performance (1 RCT, 164 participants). We are uncertain about the effect of collective leadership on clinical performance (1 RCT, 60 participants). We are uncertain about the intervention effect on healthcare outcomes, including health status (inpatient mortality) (1 RCT, 60 participants). Collective leadership may slightly improve staff well-being by reducing work-related stress (1 RCT, 164 participants). We identified no direct evidence concerning burnout and psychological symptoms. We are uncertain of the intervention effects on unintended consequences, specifically on staff absence (1 RCT, 60 participants).  AUTHORS' CONCLUSIONS: Collective leadership involves multiple professionals sharing viewpoints and knowledge with the potential to influence positively the quality of care and staff well-being. Our confidence in the effects of collective leadership interventions on professional practice, healthcare outcomes and staff well-being is moderate in leadership outcomes, low in team performance and work-related stress, and very low for clinical performance, inpatient mortality and staff absence outcomes. The evidence was of moderate, low and very low certainty due to risk of bias and imprecision, meaning future evidence may change our interpretation of the results. There is a need for more high-quality studies in this area, with consistent reporting of leadership, team performance, clinical performance, health status and staff well-being outcomes.

Communication Disparities between Nursing Home Team Members

Optimal care in nursing home (NH) settings requires effective team communication. Certified nursing assistants (CNAs) interact with nursing home residents frequently, but the extent to which CNAs feel their input is valued by other team members is not known. We conducted a cross-sectional study in which we administered a communication survey within 20 Utah nursing home facilities to 650 team members, including 124 nurses and 264 CNAs. Respondents used a 4-point scale to indicate the extent to which their input is valued by other team members when reporting their concerns about nursing home residents. We used a one-way ANOVA with a Bonferroni correction. When compared to nurses, CNAs felt less valued (CNA mean = 2.14, nurse mean = 3.24; p < 0.001) when reporting to physicians, and less valued (CNA mean = 1.66, nurse mean = 2.71; p < 0.001) when reporting to pharmacists. CNAs did not feel less valued than nurses (CNA mean = 3.43, nurse mean = 3.37; p = 0.25) when reporting to other nurses. Our findings demonstrate that CNAs feel their input is not valued outside of nursing, which could impact resident care. Additional research is needed to understand the reasons for this perception and to design educational interventions to improve the culture of communication in nursing home settings.

Working Dynamics of Licensed Nurses and Nurse Aides in Nursing Homes: A Scoping Review

Collaboration between licensed nurses (LNs) and nurse aides (NAs) is critical in the provision of quality care for residents living in nursing homes (NHs). The current scoping review explores how working dynamics between LNs and NAs in the NH setting are researched and described in the literature. Thirty-five articles were identified and reviewed that address the LN/NA relationship in the context of (a) the LN role as a supervisor and leader; (b) variation in structure; (c) expanding, understanding, and supporting staff roles; and (d) communication. We found that the LN/NA relationship has been primarily explored through the LN lens and often studied in the context of role expansion and revision associated with new models of care. Our contribution to the literature includes the following main points: efforts to improve LN/NA collaboration may be hindered without substantial structural change; collaboration may be limited within the hierarchal LN/NA relationship; LNs and NAs in NHs need greater support, recognition, and empowerment; and NAs require a representative voice. [Journal of Gerontological Nursing, 48(5), 27-34.].

Leadership for quality in long-term care

Leadership in long-term care is a burgeoning field of research, particularly that which is focused on enabling point of care staff to provide high-quality and responsive healthcare. In this article, we focus on the relatively important role that leadership plays in enabling the conditions for high-quality long-term care. Our methodological approach involved a rapid in-depth ethnography undertaken by an interdisciplinary team across eight public and non-profit long-term care homes in Canada, where we conducted over 1,000 hours of observations and 275 formal and informal interviews with managers, staff, residents, family members and volunteers. Guiding our analysis post hoc is the LEADS in a Caring Environment framework. We mapped key promising leadership practices identified by our analysis and discuss how these can inform the development of leadership standards across staff and management in long-term care.

Understanding good leadership in the context of English care home inspection reports

PURPOSE

As part of their inspection of care homes in England, the statutory inspector (the Care Quality Commission [CQC]) makes a judgement on the quality of the home's leadership. Their view is critical as it is intended to inform consumer choice and because the statutory nature of inspection means these views hold considerable authority. The purpose of this paper is to look at the content of a selection of reports and seek to determine what the CQC understands by the concept of "good leadership".

DESIGN/METHODOLOGY/APPROACH

A purposive sample of recent CQC inspection reports was selected and subjected to a qualitative content analysis. Inspections are structured around five main questions. The resulting themes describe areas of focus within the section of reports that feature the question "Are they well-led?".

FINDINGS

Inspection reports were found to focus on four main themes: safety and quality of care; day-to-day management of staff; governance and training in the home; and integration and partnership working. In the discussion section, the authors reflect on these themes and suggest that the CQC's view of leadership is rather limited. In particular, while an emphasis is placed within the literature and policy on the importance of leadership in delivering change and quality improvement, little attention is paid to this within the leadership section of inspection reports.

RESEARCH LIMITATIONS/IMPLICATIONS

The authors' research is based on a small-scale sample of inspection reports; nevertheless, it suggests a number of avenues for further research into the way in which leadership and management capabilities are developed and monitored in the sector.

ORIGINALITY/VALUE

The analysis in this report offers a view of how the inspection regime implements its own guidance and how it assesses leadership. The reports, as public-facing documents, are artefacts of the inspection regime and critical not just as evidence of the practice of inspection but as influence on care home operations and the choices of care home residents and their families.

The essentials of nursing leadership: A systematic review of factors and educational interventions influencing nursing leadership

BACKGROUND

Nursing leadership plays a vital role in shaping outcomes for healthcare organizations, personnel and patients. With much of the leadership workforce set to retire in the near future, identifying factors that positively contribute to the development of leadership in nurses is of utmost importance.

OBJECTIVES

To identify determining factors of nursing leadership, and the effectiveness of interventions to enhance leadership in nurses.

DESIGN

We conducted a systematic review, including a total of nine electronic databases.

DATA SOURCES

Databases included: Medline, Academic Search Premier, Embase, PsychInfo, Sociological Abstracts, ABI, CINAHL, ERIC, and Cochrane.

REVIEW METHODS

Studies were included if they quantitatively examined factors contributing to nursing leadership or educational interventions implemented with the intention of developing leadership practices in nurses. Two research team members independently reviewed each article to determine inclusion. All included studies underwent quality assessment, data extraction and content analysis.

RESULTS

49,502 titles/abstracts were screened resulting in 100 included manuscripts reporting on 93 studies (n=44 correlational studies and n=49 intervention studies). One hundred and five factors examined in correlational studies were categorized into 5 groups experience and education, individuals' traits and characteristics, relationship with work, role in the practice setting, and organizational context. Correlational studies revealed mixed results with some studies finding positive correlations and other non-significant relationships with leadership. Participation in leadership interventions had a positive impact on the development of a variety of leadership styles in 44 of 49 intervention studies, with relational leadership styles being the most common target of interventions.

CONCLUSIONS

The findings of this review make it clear that targeted educational interventions are an effective method of leadership development in nurses. However, due to equivocal results reported in many included studies and heterogeneity of leadership measurement tools, few conclusions can be drawn regarding which specific nurse characteristics and organizational factors most effectively contribute to the development of nursing leadership. Contextual and confounding factors that may mediate the relationships between nursing characteristics, development of leadership and enhancement of leadership development programs also require further examination. Targeted development of nursing leadership will help ensure that nurses of the future are well equipped to tackle the challenges of a burdened health-care system.

Consistent assignment in long-term care homes: Avoiding the pitfalls to capitalise on the promises

BACKGROUND

Consistent assignment (CA) is the practice within long-term care (LTC) by which care staff work with the same residents almost every shift for an indefinite period of time. CA is considered by many to be essential to person-centred care.

OBJECTIVES

This paper explores how staff assignment practices impact the caregiving experience from the perspectives of resident care aides (RCAs), residents and family members and, by doing so, describe the nuanced conditions under which CA may or may not be beneficial to all, and why.

METHODS

Data are drawn from 40 in-depth interviews conducted as part of a larger institutional ethnography exploring the social organisation of care in three purposively selected LTC homes in Western Canada. Data analysis was based on the principles of constant comparison.

RESULTS

RCAs, residents and family members described the primary benefit of CA as being able to 'get to know' each other well and form meaningful relationships. However, the RCAs also indicated that CA can contribute to feelings of isolation, which has negative effects on worker comfort and satisfaction, care team dynamics and communication, and resident care.

CONCLUSIONS

Management initiatives are needed to ensure that the implementation of CA does not result in the unintended consequences of decreasing RCAs' experience of teamwork, decreasing RCAs' exchange of individualised resident care information, or negatively impacting RCAs' ability and desire to care for each other as well as the residents.

IMPLICATIONS FOR PRACTICE

The staffing practice of consistent assignment in long-term care homes provides increased opportunities for the development of stronger staff-resident and staff-family member relationships. Findings from this study enable us to offer several, evidenced-based recommendations for ensuring the successful implementation of consistent assignment, such that it may be beneficial to all.

Stakeholder Engagement in Practice Change: Enabling Person-Centred Mealtime Experiences in Residential Care Homes

Person-centred care is recognized as best practice in dementia care. The purpose of this study was to evaluate the effectiveness of a stakeholder engagement practice change initiative aimed at increasing the provision of person-centred mealtimes in a residential care home (RCH). A single-group, time series design was used to assess the impact of the practice change initiative on mealtime environment across four time periods (pre-intervention, 1-month, 3-month, and 6-month follow-up). Statistically significant improvements were noted in all mealtime environment scales by 6 months, including the physical environment (z = -3.06, p = 0.013), social environment (z = -3.69, p = 0.001), relationship and person-centred scale (z = -3.51, p = 0.003), and overall environment scale (z = -3.60, p = 0.002). This practice change initiative, which focused on enhancing stakeholder engagement, provided a feasible method for increasing the practice of person-centred care during mealtimes in an RCH through the application of supportive leadership, collaborative decision making, and staff engagement.

Reliability Testing of the Team Member Mealtime Experience Questionnaire

Team members influence the mealtime experience of residents. Their perspectives on their ability to provide resident- and relationship-centred care during mealtimes is limited. The aim of this study was to describe the development and determine the factor structure and internal and test-retest reliability of the Team member Mealtime Experience Questionnaire (TMEQ). A 23-item questionnaire was developed through several steps. A Likert scale of strongly disagree (score= 1) to strongly agree (score= 5) was used. A total of 137 team members from five diverse homes participated. Time and task-focused items had lower scores (indicating more negative perceptions), whereas knowledge and capability of how to provide resident- and relationship-centred mealtime care had higher scores. Exploratory factor analysis identified three factors; four items were eliminated based on this analysis. Test-retest reliability was completed with 103 participants. Intraclass correlation (ICC) for the total score and three subscales ranged from 0.72 -0.85 while Chronbach's alpha ranged from 0.81-0.92. The 19-item TMEQ is considered reliable for use in research and practice.