• Open Access

Effective nursing leadership of older persons in the community – a systematic review

Authors

  • Anne Lise Holm RPN, MNSc, PhD,

    Postdoctoral Research Fellow, Associate Professor, Corresponding author
    1. Centre for Women's, Family and Child Health, Faculty of Health Sciences, Vestfold University College, Tønsberg, Norway
    2. Department of Nursing Education, Stord/Haugesund University College, Stord, Norway
    • Correspondence

      Anne Lise Holm

      Department of Nursing Education

      Stord/Haugesund University College

      Fartein Valensgate 3b

      N-5532 Haugesund

      Norway

      E-mail: anne.holm@hsh.no

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  • Elisabeth Severinsson RPN, RNT, MCSc, DrPH

    Professor and Director of Research, Research Department
    1. Centre for Women's, Family and Child Health, Faculty of Health Sciences, Vestfold University College, Tønsberg, Norway
    2. Stavanger University Hospital, Stavanger, Norway
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Abstract

Aim

The aim of this systematic review was to increase the knowledge of developing effective nursing leadership and management in order to improve the outcomes of older persons in the community.

Background

There is a need for increased knowledge of nursing leadership and management in order to improve the outcomes of older persons in the community.

Evaluation

A review of the literature published in different databases between January 2000 and May 2012 was conducted. Eleven articles met the inclusion criteria and were evaluated by means of thematic content analysis.

Key aspects

Six themes were identified: Ability to change the attitudes towards older persons; Building trust; Ensuring efficacy in management decisions; Lack of knowledge about how to overcome relational challenges; Health system collaboration to achieve goals and visions; and Staff members' experiences of the meaning of and possibility to influence their work, all of which are of importance for effective nursing leadership and management in the care of older persons.

Conclusion

Advanced nursing knowledge is necessary in order to improve the work and vision involved in nursing leadership and management.

Implications for nursing management

Findings indicate that relational and organisational abilities are necessary components of effective nursing leadership and management.

Introduction

According to the World Health Organization (WHO 2002), many countries need to make radical changes in health and home care for older persons. In order to achieve this goal, communities are expected to develop effective nursing leadership and management. Marquis and Huston (2000) suggested that leadership and management are two sides of the one coin. Both are necessary to ensure high quality organisational service and performance. The need for increased knowledge of nursing leadership and management is of the greatest importance to maximize the health outcomes of coordinated multidisciplinary care delivery and management (Rosenblatt & Woodbridge 2003). Nursing leadership and management in the care of older persons have been described as complex. Although there are several definitions of old age, no general consensus exists on the age at which a person becomes old. However, most developed countries have accepted the chronological age of 65 years as a definition of an ‘elderly’ or older person (WHO 2012).

Recommendations have been made in many countries to develop new roles that can promote responsibility for ensuring that staff skills meet patient needs (Department of Health [DoH] (2001), Pritchard & Wright 2001, DoH 2006). McKenna and Bradley (2004) found that strong leadership is necessary for the development of community nursing, but that there is confusion and disagreement over whether it currently exists. Ford et al. (2008) presented a leadership development programme for Nurse Directors of Older People's Services. The programme was considered useful at times of great opportunity and challenge.

The changes in the health care system have resulted in different expectations on the role, skills and knowledge of leadership and management in community nursing. The first-line nurse manager (FLNM) role has been subject to many changes due to shifts in health and home care both nationally and internationally (Duffield 1992). In Australia, Duffield et al. (2001, p. 786) stated that ‘new positions for nurse managers with enhanced and extended responsibilities are a prominent feature of today's health care system’. First-line nurse managers are not only ‘managers’, but also leaders who coach, direct and encourage their staff (Duffield et al. 2001). A study from Sweden revealed that the decentralization of decision making has changed the FLNM role from overall responsibility for patients to overall responsibility for the quality of patient care, personnel and budgets (Skytt et al. 2008). The increased responsibility is intended to lead to effectiveness and efficiency in organisations (Nicklin 1993). Thorpe and Loo (2003) stated that FLNMs are key players who face major challenges as well as demands for efficiency on a daily basis. The FLNMs need organisational support if they are to achieve high job satisfaction and to remain in their current positions as leaders and managers in elder care (Lee & Cummings 2008). According to Hyrkäs et al. (2005) the work of FLNMs in Finland has undergone an enormous change. Administrative tasks have been transferred from directors of nursing to nurse managers. At the same time, the need to participate directly in patient care in the delivery of health care has increased. The FLNMs consider this as the main cause of stress (Hyrkäs et al. 2005).

Consultant nurses (CNs) were introduced in the UK in 2000 (McIntosh & Tolson 2009). According to McIntosh and Tolson (2009), nursing research identifies leadership as a key element of the consultant nurse role, with postholders adopting transformational leadership approaches. The consultant nurse role is described as a foundation for transformation in practice as well as management and leadership functions (National Health Service Executive 1999). Consultant nurses have a master level education that enables them to deliver expert clinical practice, education, consultancy and research. Abbott (2007) found that CNs work in a large number of disciplines, departments and organisations. However, little has been written about the consultant nurse role in relation to the nursing of older persons and to date no evidence base for the effectiveness of the role exists (Clegg & Mansfield 2003, Webster 2004).

Transformational leadership as described by Bass (1985) can be used to understand nursing leadership and management, especially in times of organisational change. The characteristics of transformational leadership identified by Bass (1985) involve leaders and managers keeping their promises, behaving consistently in line with their promises and gaining trust. Thus, building trust is of the utmost importance in developing leadership and management when nursing older persons. Positive relationships between transformational leadership and organisational health have been found in many studies (e.g. Bass & Avolio 1994, Avolio & Yammarino 2002, Judge & Piccolo 2004, Pillai & Williams 2004, Walumbwa et al. 2004). Lynch et al. (2011) described situational leadership as one form of transformational leadership that can be used to develop a person-centred nursing framework in the care of older persons.

The Clegg and Mansfield (2003), World Health Organization (WHO) (2003)as well as Shearer et al. (2010) stated that one of the hallmarks of community health and home care is empowering and enabling older persons to regain or maintain a level of independence and well-being. Knowledge gaps need to be identified by means of reviews in order to increase the knowledge of developing effective nursing leadership and management that can improve the outcomes of older persons in the community. To the authors’ knowledge, no systematic review has done this before.

Aim

The aim of this systematic review was to increase the knowledge of developing effective nursing leadership and management to improve the outcomes of older persons in the community.

Method

The purpose of a systematic review is to gather and summarize existing research and knowledge, irrespective of the methods used in the primary studies (Conn et al. 2003, Holopainen et al. 2008). This is in line with Dixon-Woods et al. (2005), who argued that the exclusion of any type of evidence on the grounds of its methodology could have potentially serious consequences. The present systematic review includes quantitative and qualitative studies. Goding and Edwards (2002) and Hewitt-Taylor (2002) claimed that the results of qualitative studies are needed in evidence-based nursing (Goding & Edwards 2002, Hewitt-Taylor 2002).

Literature search

The OVID MEDLINE, PubMed, EBSCOhost/Academic Search Premier and CINAHL electronic databases were searched for the period January 2000–May 2012. The search words used in combination and separately were community nursing, elder/older, health, home care, leadership, management. A total of 393 abstracts were read and 50 studies were retrieved for further investigation. These abstracts included review papers, non-empirical research as well as theoretical and empirical research studies, the majority of which did not fulfil the inclusion criteria. A second, narrower search was carried out in May 2012 in the same databases adding nursing to leadership and management to the search words in order to search for some new nursing research on the topic. Some new abstracts (58) were retrieved for further investigation. Two relevant studies were included. A subsequent manual search was related to the topic of the relevant papers and their significant references. One relevant study was retrieved.

The retrieval and selection process is illustrated in Figure 1.

Figure 1.

Search and retrieval process.

Inclusion and exclusion criteria

Although a total of 451 abstracts were read and 53 papers retrieved, only 11 met the inclusion criteria; peer-reviewed papers, published in English, elder/older, empirical research, health care, home care, nursing, management and leadership. Exclusion criteria were inpatient settings in non-community institutions, research focusing on the needs of older persons without relating them to health or home care, leadership, management and/or nursing leadership and management. Three quantitative and eight qualitative studies were included in the review irrespective of the research methods used or the strength of evidence (Table 1).

Table 1. The included qualitative studies
1st author, year, reference, countryDesign, methodSample, analysisContextSummary of outcomes

1. Arbon et al. (2008)

Australia

Mixed method.

This study included qualitative data.

= 8 (residential eldercare facility setting).

Individual interviews and a focus group. Full details were provided in the project report (ACT Government 2005)

= 5 (community), = 4 (acute hospital).

Thematic analysis

The study was undertaken in Australian Capital Territory, which, in common with other Australian states and territories, is developing the Nursing Practitioner (NP) roleThe findings demonstrated a significant improvement in client outcomes as a result of the implementation of a transboundary nurse practitioner model for the care of older persons. The improved outcomes were associated with a decrease in acute hospital admissions for residential care clients, timely intervention for a range of common conditions and strengthened multidisciplinary approaches to care provision for elderly persons

2. Duncan and Reutter (2006)

Canada

Qualitative study

= 23.

Thematic, comparative, critical analysis

The subsystem of home care within a regional health system during the period 1993–2001The critical analysis revealed that the emerging policy agenda in regional home care is one of medicalization, which is contrary to primary care principles and potentially leads to further marginalization of the most vulnerable. This contradiction is characterized by conflict with the fundamental values of equity and efficiency, choice and universality, as well as public vis-à-vis individual responsibility for the provision of care

3. Henriksen and Rosenqvist (2003)

Sweden

Qualitative study

= 12, = 8

Inductive analysis

Political municipal chairpersons and managers responsible for the care of older persons, in addition to the chairperson, vice-chairperson and executive manager of the north-western sector of greater Stockholm participated in the studyThe differing ways of understanding elder care services led to a complex and fragmented organisation lacking clear goals, structures and leadership. However, the authors found a willingness among the respondents to collaborate with each other, as well as indications of positive attitudes towards improving home care/healthcare, domiciliary and nursing care of older people

4. Henriksen et al. (2003)

Sweden

Qualitative study

= 19

Content analysis

Municipal managers and politicians, two local county council representatives and health care organisation managersThe main result was that all participants agreed on four key visions of healthcare for the elderly: see the person, see her/his resources, see the encounter, and see yourself. Other findings indicated that (1) care of older persons was governed by diverse interests, (2) the organisation lacked clear leadership and comprehensive goals, (3) the organisation was fragmented and (4) there was a lack of skilled staff members to meet patient needs. Older persons were regarded as passive recipients of care or as objects that did not play an active role in health care decisions that affected them

5. Johansson et al. (2007)

Sweden

Qualitative study

= 1 (case study).

Hermeneutic analysis

The study was conducted at a nursing home unit in Sweden. The staff comprised 22 assistant nurses/nurse's aides, nine nurses and one-first-line nurse managerThe results indicated that the first-line nurse manager had three goals; (1) A nursing goal that she strongly adhered to and demonstrated excellent control, (2) an administrative goal that she adhered to and exhibited control, (3) a leadership goal that she did not accept and where she had no control. The administrative and leadership goals were based on her job description, but the nursing goal was personally chosen on the basis of self-reflection and goal-fulfilment

6. Manley et al. (2008)

UK

Qualitative study

= 9.

Interpretative phenomenological analysis

A 6-month cooperative approach was used to develop insights into the leadership strategies of Consultant Nurses working in the care of older persons and involved the five authors and four Consultant Nurses. The main author was a Consultant Nurse and practice based researcher from a different nursing areaTwo key themes emerged relating to complexity and pathways, which provided a major focus for the Consultant Nurses’ leadership role. The outcome of the study is a framework that describes the triggers and enabling factors that precede the use of leadership strategies at clinical and organisational levels as well as the results achieved

7. Ross et al. (2005)

UK

Mixed method.

Qualitative data

= 9

Diagnostic analysis

The study was one of nine implementation projects to evaluate evidence-based change in nine health care settings south of the Thames

in London

This paper draws on descriptive and qualitative data and addresses the links between contextual issues and the processes and pathways of change. Key themes were: Working through others and across boundaries and Managing uncertainty and unanticipated challenges. Ward staff adherence to the multidisciplinary assessment guidelines was high, with evidence of some dissemination to community staff at follow-up. Three years after the project finished, multidisciplinary assessment still formed part of routine clinical practice

8. Smith Higuchi et al. (2002)

USA

Ethnographic design.

Qualitative study

= 16

Analysis not described

A small urban home care office in southern Alberta, Canada employing home care nurses who are responsible for the care of approximately 700 clients and their familiesThe findings indicated that the decision-making challenges in home care practice comprised four major categories: The development of client-centred care plans: The home care practice environment: Developing confidence in clinical decision making: and ethical decision making

Data analysis

This systematic review was carried out by means of thematic content analysis and the authors organised the findings in accordance with the themes identified in the data. According to Holopainen et al. (2008), the methods of analysing a systematic review can be either statistical or qualitative, depending on the purpose and the material involved.

The studies included a variety of data and depths of interpretation. The authors discussed how to interpret the studies in order to expand the meaning of the text in the light of their own preunderstanding as psychiatric nurses and researchers. Their preunderstanding can have influenced the interpretation of the analyses as described by Denzin and Lincoln (2003).

DeSantis and Ugarriza (2000, p. 362) stated that ‘a theme is an abstract entity that brings meaning and identity to a current experience and its variant manifestations’. A theme may thus combine different experiences into a meaningful whole (cf. DeSantis & Ugarriza 2000). Analysis of the text concerns visible and obvious components, referred to as the manifest content (Graneheim & Lundman 2004). Both manifest and latent content require interpretation, but the interpretations vary in depth and level of abstraction. Thematic content analysis is suitable for articles and other written material (Graneheim & Lundman 2004, Cavanagh 1997). A theme answers the question ‘how?’ and as Graneheim and Lundman (2004) suggested, is a thread of an underlying meaning on an interpretative level.

In the first step, the included studies were read as open-mindedly as possible to gain an impression of each study as a whole, as well as a general understanding of effective nursing leadership and management that could be used to improve the outcomes for older persons in the community. The second step involved abstraction by means of reading and comparison, after which abstractions related to the same content were grouped together (cf. Graneheim & Lundman 2004). In the third step, the text was structured into emerging themes. It is essential that authors achieve consensus about the themes and understanding of the underlying meanings embedded in the included studies.

Both authors were familiar with thematic content analysis, which could increase trustworthiness, as described by Holopainen et al. (2008). According to Droogan and Song (1996) and Magarey (2001), the participation of different researchers in the selection and analysis of studies increases the credibility of a systematic review.

Determining quality of the included studies

The methodological quality and evaluation of the quantitative studies was assessed in accordance with the PRISMA (2009) checklist. The authors critically assessed the methodological procedures in terms of: design, sample size, and selection bias, reliability, threats to validity and generalization (Schneider et al. 2007, Polit & Beck 2010). The qualitative studies were evaluated with regard to trustworthiness (Graneheim & Lundman 2004, Lincoln & Guba 1985). Other aspects of the included studies were demographic characteristics, ethical approval and context.

Results

Design, sample size

One of the two quantitative studies was a pilot study (Faulk et al. 2008) (see Table 2). Two of the three quantitative studies (Faulk et al. 2008, Abdelrazek et al. 2010) using small samples and contained no information about the response rate and risk of bias.

Table 2. The included quantitative studies
1st author, year, reference, countryDesignSampleReliability/Validity of measurementsAnalysisSummary of outcomes
  1. COPSOQ, Copenhagen psychosocial questionnaire; CWEQ-11, conditions of work effectiveness questionnaire II; FLNMs, first-line nurse manager; GTLS, global transformational leadership scale; LaMI, leadership and management skill; RMSEA, root mean square error of approximation; SWQ, satisfaction with work questionnaire.

1. Abdelrazek et al. (2010)

Egypt

Comparative design

98 first- line managers (FLMs) working in eldercare. = 49 (from Egypt).

= 49 (from Sweden)

CWEQ-II (Laschinger et al. 2001) LaMI

SWQ (Engström et al. 2010). Internal consistency and reliability of the factors and scales were measured using Cronbach's alpha

Descriptive statistical analysis. The Mann–Whitney U-test, chi-square test and Fisher's exact test were used to compare variables between Egypt and SwedenThe work environment, both in Egypt and Sweden, needs to be improved to increase FLMs' job satisfaction and reduce stress. The management culture and levels differ between the two countries

2. Faulk et al. (2008)

USA

Pilot study= 15Modified test bank questions were used to measure learning for each module. An assessment of attitudes related to caring for the elderly was also includedDescriptive statistical analysis. Independent samples t test was used to analyse differences in the pre-and post-test scores at a predetermined significance level of < 0.05Written comments in an evaluation survey of a programme indicated increased knowledge. The completion of the programme contributed to improvements in LPNs' basic leadership and management skills. The results revealed that LPNs changed their professional behaviour towards the older persons as a consequence of the programme. The LPNs also tried to listen to the older persons and be more sensitive to their feelings

3. Nielsen et al. (2008)

Denmark

A cross-section-al longitudinal design.= 447

GTLS (Carless et al. 2000). The GTLS has a high degree of convergent validity.

COPSOQ (Kristensen et al. 2002, 2006). The scales have been found to have good reliability and validity

Statistical confirmative factor analysis.

The measurement model used to test the proposed six factor model indicated a good fit to the data: X2 (309) = 727.36, < 0.001, RMSEA = 0.055

The transformational leadership style was closely associated with the staff members' work environment, namely involvement, influence and meaningfulness. Involvement was related to job satisfaction and meaningfulness to well-being. A direct path was found between leadership behaviour and staff well-being

Measurements

The two studies by Faulk et al. (2008) and Abdelrazek et al. (2010) did not discuss the validity or reliability of the measurements employed. However, Faulk et al. (2008) recommended replicating the research. Abdelrazek et al. (2010) stated that future studies could explore workload, expectations and demands in greater depth.

Generalization

Faulk et al. (2008) stated that their findings could not be generalized to other populations or settings, while Abdelrazek et al. (2010) claimed that their data could be generalized to First-Line Managers (FLM) working in elder care. See Table 2 for further information about the validity and reliability of the measurements used and the statistical analyses of the included studies. Even if the quality of the two quantitative studies were low in evidence they have knowledge about effective nursing leadership and management and thus were not excluded from the systematic review.

Trustworthiness

When determining the quality of the qualitative studies, the methodological aspects of the trustworthiness were examined. Three studies used member checking as a way to strengthen the validity of the analysis (Smith Higuchi et al. 2002, Johansson et al. 2007, Arbon et al. 2008). Two studies discussed how the authors ensured credibility and promoted validity (Ross et al. 2005, Johansson et al. 2007). Two studies explained that further research is required to improve practice (Henriksen & Rosenqvist 2003, Arbon et al. 2008).

Demographic data

The three quantitative studies included demographic data (Faulk et al. 2008, Nielsen et al. 2008, Abdelrazek et al. 2010) while none of the qualitative studies contained such information.

Ethical approval

Two of the quantitative studies (Faulk et al. 2008, Abdelrazek et al. 2010) and four qualitative studies (Smith Higuchi et al. 2002, Ross et al. 2005, Johansson et al. 2007, Arbon et al. 2008) stated that ethical approval had been obtained from an institutional review board.

Results from the thematic content analysis

Effective nursing leadership of older persons in the community relates to the following six themes: Ability to change the attitudes towards older persons; Building trust; Ensuring efficacy in management decisions; Lack of knowledge about how to overcome relational challenges; Health system collaboration to achieve goals and visions; and Staff members' experiences of the meaning of and possibility to influence their work, all of which are of importance for effective nursing leadership and management in the care of older persons.

Ability to change the attitudes towards older persons

Two studies (Henriksen & Rosenqvist 2003, Duncan & Reutter 2006) revealed that managers were aware of an attitude problem among their staff towards older persons. In the study by Henriksen and Rosenqvist (2003) the managers described taking care of older persons in a traditional sense, i.e. as passive rather than active recipients of care, and failed to empower people to take responsibility for as well as command over their own life situation. They complained about the emphasis on the medical paradigm and questioned who was responsible for the care of elderly people (Henriksen & Rosenqvist 2003). Duncan and Reutter (2006) stated that managers need to develop a new value and meaning of caring for older persons when the shift to a medical model is widespread. The managers in their study expressed concern that older and socially isolated individuals were ‘falling through the cracks' (Duncan & Reutter 2006).

Building trust

Four studies revealed that building trust and support were important elements of leadership and management in the care of older persons (Henriksen & Rosenqvist 2003, Johansson et al. 2007, Arbon et al. 2008, Faulk et al. 2008). Henriksen and Rosenqvist (2003) found that the managers described trust as a crucial element of the organisational culture. Arbon et al. (2008) reported that spending time with and paying full attention to an elderly person was of the utmost importance. Johansson et al. (2007) described that a first-line manager's intention was that there should be a social feeling of togetherness between the older persons and staff, although the latter expressed uncertainty about how they should communicate this message. Faulk et al. (2008) linked older persons' psychosocial need of basic trust to the way nurse managers listened to them and suggested that they should treat older persons as individuals instead of a group.

Ensuring efficacy in management decisions

Three studies described different aspects of the need for efficiency in management decision-making (Henriksen & Rosenqvist 2003, Duncan & Reutter 2006, Faulk et al. 2008). Henriksen and Rosenqvist (2003) revealed that modern trends including a language of efficiency, productivity, growth, innovation and short-term profit are difficult to apply in the care of older persons. Duncan and Reutter (2006) found that the demand for decision-making efficiency resulted in the loss of services that enabled older persons to remain at home, which in the long term would have avoided more costly care options. Faulk et al. (2008) recommended sharing information before making decisions.

Lack of knowledge about how to overcome relational challenges

Five of the included studies reported the need for increased knowledge of how to overcome challenges such as problems associated with communication and/or collaboration as a leader and manager in the care of older persons (Smith Higuchi et al. 2002, Henriksen & Rosenqvist 2003, Ross et al. 2005, Arbon et al. 2008, Manley et al. 2008). Smith Higuchi et al. (2002) stated that it was essential that managers encourage and support opportunities for peer consultation through daily meetings given the isolated nature of the home care practice environment. Henriksen and Rosenqvist (2003) revealed that communication could improve quality of life and thus strengthen and support older persons in a more effective manner. Ross et al. (2005) described the role of leader as crucial to the process of working to overcome setbacks and managing the emotional, interpersonal and organisational challenges of dynamic and unpredictable change. Arbon et al. (2008) demonstrated the need for advanced nursing knowledge in the care of older persons. Manley et al. (2008) illustrated that the role of the consultant nurse was to increase knowledge and to promote attitudes that could facilitate older persons and staff throughout the health care system. The consultant nurse leader needs to work across boundaries and use extensive networks so that the patient could obtain care that was right for her/him, while the leader was involved in the ability to ‘see’, ‘construct’, enable and navigate alternative pathways for older persons and organisations.

Health system collaboration to achieve goals and visions

Two studies described that both leaders and manager need to create specific goals and visions (Henriksen et al. 2003, Johansson et al. 2007, Manley et al. 2008). Henriksen et al. (2003) stated that the goals must be well-defined, easily understood and remembered, relevant to all staff members and applicable on all care levels. The goals must also focus on older persons' quality of life and describe what staff should do to enhance it. Johansson et al. (2007) revealed that although there were overall goals for the care of older persons, common goals at unit level were lacking.

Staff members' experiences of the meaning of and possibility to influence their work

Two studies described that staff members' experiences of the meaning of and possibility to influence their work were of importance (Nielsen et al. 2008) and Manley et al. (2008) stated that influence was important for effective nursing leadership and management in the care of older persons. According to Manley et al. (2008), the Consultant Nurse used a number of other strategies to directly influence staff, including seizing all opportunities, as well as being opportunistic and intentional in using any situation that emerged to develop practice. Nielsen et al. (2008) proposed that such experiences could partially explain how transformational leadership behaviours are related to a work environment in which the professionals perceive their duties as meaningful, are involved in their job and experience having a high degree of influence.

Discussion

This study investigated developing effectiveness in the care of older persons in a community from nursing leadership and management perspectives. Six themes emerged: Ability to change the attitudes towards older persons; Building trust; Ensuring efficacy in management decisions; Lack of knowledge about how to overcome relational challenges; Health system collaboration to achieve goals and visions; and Staff members' experiences of the meaning of and possibility to influence their work, all of which are of importance for effective nursing leadership and management in the care of older persons. This is supported by Wong and Cummings (2007), who highlighted the associations between leadership behaviours and increased patient satisfaction. Values regarding and attitudes towards older persons seem to be a problem in nursing. The skills needed of leadership and management appeared to be related to the ability to change some existing attitudes. Understanding nursing leadership and management, especially in times of organisational change due to transformational leadership (Bass 1985), is an important organisational strategy for improving patient outcomes (Wong et al. 2010). However, encouraging leaders and managers to keep their promises and behave consistently in line with the three types of transformational behaviour: idealized influence, intellectual stimulation and individualized considerations (Bass 1985), may be difficult when the professional practice environment is largely driven by cost considerations (Hinno et al. 2011). Duncan and Reutter (2006) revealed that some of the so-called negative attitudes can be related to the view of older persons within the medical paradigm and might limit both health promotion and prevention. The medical paradigm is described as a pathogenic perspective because the older persons are seen as objects rather than independent individuals. The consequence is that the older persons can develop feelings of powerlessness and helplessness in their struggle against the system. Attitudes in a community can be described from three perspectives: knowledge and perceptions of aging or older persons; positive or negative emotions; and a preparedness to act when confronted by the attitude that sees older persons as objects (Henriksen et al. 2003).

In what way can building trust be a responsibility of leadership and management? Erikson (1980) defines trust as one of the fundamental stages reached early in life and, by trusting another, one places oneself in a dependent and vulnerable position. Distrust can thus be a sign that the health and home care services lack enough or sufficiently qualified staff. Distrust can develop in an environment in which an existential attitude is absent (cf. Tillich 1970), as the nurses and health care professionals do not include the older persons' perspectives or listen to their needs. Gaining trust is described by Bass (1985) as an essential part of transformational leadership. In Faulk et al. (2008) gaining trust seems to have the same intention as Erikson's (1980) stages of psychosocial development. Building an existential attitude of trust can be a way of including the old person's perspectives and desires. Leadership and management also have an important role when reflecting on situations where nurses and other professionals can threaten the older persons' integrity. Awareness of older persons' integrity can help nursing management and leadership to develop existential attitudes towards ageing. One strategy can be to encourage staff members to form ethical reflection groups where the dignity of older persons is focused upon (cf. Randers & Mattiasson 2004). Abdelrazek et al. (2010) revealed that Egyptian society's great respect for the elderly was related to the fact that working in elderly care has a higher status in Egypt than in Sweden.

Decision-making in nursing care seemed to be influenced by triggers that allowed the nurse manager to identify lack of continuity in eldercare. Efficacy can be a problem for nursing leadership and management, as treatment-oriented health care services seem to be prioritized at the expense of long-term care in the home (cf. Duncan & Reutter 2006). The growing demand for efficacy in community nursing can be related to the increasing influence of efficiency theories in the political and public domain in many parts of the world, and two of the studies included in the review revealed this trend (Henriksen & Rosenqvist 2003, Henriksen et al. 2003). However, can it be morally justified to treat the care of older persons as a market place? Evaluation of efficiency needs to take account of the impact of such demands and how they influence the quality of home care for the elderly. In the long term, this situation could lead to stress and poor health for all concerned – the old persons, their families and health care professionals.

Developing common goals seems to be important for leaders, and a lack of goals can explain the confusion and feelings of distrust in the health care system. Developing a joint care service can be one way of meeting this relational challenge (cf. Henriksen & Rosenqvist 2003). Advanced nursing knowledge is of the utmost importance for changing older persons' worlds, as well as the culture of the work place and the organisation as described by Manley et al. (2005). In order to overcome relational challenges one needs a balanced picture of the goal and function of leadership. Leaders and managers can be of great help to staff in building different professional networks around the older person.

The findings show that collaboration, communication and networks have been identified as important aspects of nursing leadership and management, a conclusion supported by Mezey and Fulmer (2002). Concern could be related to confusion about the scope of the role and poor role definition. Thus nursing leadership and management can develop as the role matures, thus making a significant impact on the care of older persons (cf. Arbon et al. 2008). The leader and manager need to modify and simplify the goals and priorities to achieve change. In order to progress it seems crucial to maintain enthusiasm and motivation in terms of outcomes. However, staff members need confidence that their decisions are worthwhile. The premise of transformational leadership is that development of a shared vision is one element of effective nursing leadership (Manley et al. 2008, Nielsen et al. 2008). Such a vision could be based on strengthening both the social system that relies on family care and the institutional system consisting of home-based elderly care (cf. Abdelrazek et al. 2010). Other characteristics were enablement of others, minimizing risk by being present, role-modelling core values, challenging and supporting (Manley et al. 2008).

Nursing leadership and management seems to need the ability to influence and contribute to the empowerment of staff and the organisation (cf. Avolio et al. 2004). The theory of transformational leadership as described by Nielsen et al. (2008) can be useful and help develop effective leadership and management in nursing. However, Nielsen et al. (2008) did not discuss the consequences of their findings for the population of older persons.

Methodological discussion

Risk of bias across studies is discussed in this section (Schneider et al. 2007, Polit & Beck 2010). According to Polit and Beck (2010), any influence that produces a distortion in the results could threaten the validity and trustworthiness and lead to bias.

One of the quantitative studies is described as longitudinal design (Nielsen et al. 2008). A longitudinal study should have an observational design, where the researchers collect data over an extended period (Schneider et al. 2007, Polit & Beck 2010). Nielsen et al. (2008) described transformational theory as offering the most plausible explanation of causality. Observational designs can be limited in their ability to determine ‘causality’ (Schneider et al. 2007, p. 163), thus the explanation by Nielsen et al. (2008) seems unnecessary in relation to validity and reliability as described by Schneider et al. (2007) and Polit and Beck (2010). However, a limitation of using an observational design might be that participants can change over time, thus the threat could be related to maturity with implications for internal validity (Polit & Beck 2010).

As statistical power depends on sample and effect size, a non-significant effect must be interpreted with caution (cf. Shadish et al. 2002). Two of the studies (Faulk et al. 2008, Abdelrazek et al. 2010) had no methodological discussion of limitation and bias related to the small sample size. These two studies employed self-report measurements (Faulk et al. 2008, Abdelrazek et al. 2010), but did not discuss how self-report questionnaires could reduce validity and reliability. Shadish et al. (2002) stated that self-report measurements can increase the likelihood of response bias. According to Polit and Beck (2010), evaluating quantitative studies includes the possibility of generalizing the findings. However, as the two studies (Faulk et al. 2008, Abdelrazek et al. 2010) had small samples, generalization must be considered with caution.

According to the qualitative study (Smith Higuchi et al. 2002) described using an ethnographic design in which the concept of culture usually is applied. However, no explanation or description of culture could be found. In the view of Schneider et al. (2007), the concept of culture is inherent in ethnography and is a way of understanding the activities and meanings of a social group. Ross et al. (2005) used a standardized design comprising a quasi-experimental before-and-after evaluation that employed evidence-based guidelines. In two studies it was stated that the interview and focus group schedules were described in another project (Ross et al. 2005, Arbon et al. 2008). However, Arbon et al. (2008) did not explain why the survey details were not presented or how the data were used. Smith Higuchi et al. (2002) included no description of an audit trail or the different steps or stages in the analysis, as recommended by Lincoln and Guba (1985). Two studies described concepts such as validation (Arbon et al. 2008) and agreement (Johansson et al. 2007). According to Schneider et al. (2007, p. 149), a way to strengthen trustworthiness is related to the concept of credibility and the ‘truth of findings as judged by participants and others within the discipline’. However, Schneider et al. (2007, p. 148) also stated that at present there is no consensus amongst researchers about how to evaluate the results of a qualitative study. The term ‘trustworthiness’ appears to be the equivalent of the term ‘rigour’ in quantitative research. One study outlined the methods used to obtain trustworthiness as well as credibility in accordance with Lincoln and Guba (1985). The two studies that applied mixed methods described elements of validity (Ross et al. 2005, Arbon et al. 2008). Arbon et al. (2008, p. 258) stated that they strengthened ‘the validity of the thematic analysis’, which could mean obtaining agreement on the interpretation of a category or theme. However, four studies lacked descriptions of trustworthiness including credibiltity, confirmabilty, dependability and transferability or validity (Smith Higuchi et al. 2002, Henriksen & Rosenqvist 2003, Henriksen et al. 2003, Duncan & Reutter 2006), which could decrease the trustworthiness of their findings as described by Graneheim and Lundman (2004) and Polit and Beck (2010).

Limitations of this review

It can be difficult to ensure trustworthiness in a synthesis of quantitative and qualitative data. Reviews are secondary research prepared by someone other than the original researcher (Polit & Beck 2012). A review of quantitative and qualitative data can be related to credibility, which concerns validation of data (Polit & Beck 2012). Another limitation can be a too broad or narrow search strategy, while new evidence can change the relevance of a review in terms of the concept of dependability, i.e. the stability of data and conditions over time as explained by Lincoln and Guba (1985). Thus the possibility of excluding some relevant studies is ever present.

In our review, three studies were from the USA and Canada, six from Europe (two from the UK and four from the Nordic countries), but only one from Australia and one from Egypt. One must take account of the different health care systems including leadership and management in various parts of the world. A limitation might be that the results cannot be directly transferred to effective leadership and management in other parts of the world. In terms of transferability, the reader of this systematic review is the one who can decide whether or not the results are applicable in her/his own context (Lincoln & Guba 1985). Additional studies in other countries are recommended in order to strengthen the trustworthiness of such reviews.

Conclusions and implications for nursing management

Despite the fact that the evidence derived from the included studies varied in quality, some important implications for nursing leadership and management can be identified. The first is to base advanced nursing knowledge on an existential approach in order to enable a common understanding of the work and vision in the care of older persons. This approach involves building nursing management and leadership knowledge of how to safeguard older persons' integrity as individuals instead of as a group. Older persons are as unique as younger ones and wish to maintain their autonomy and be responsible for their own life situation for as long as possible. Another implication is the need to reflect on the use of a language of efficiency and productivity in the care of older persons. Nursing management and leadership needs to overcome setbacks and handle relational, emotional and organisational challenges when facing unpredictable change. They have to able to work across boundaries and use networks so that the older persons can be provided with appropriate and individually tailored care.

Several implications of research of the developing of effective nursing leadership and management of the care of older persons need to be addressed, in particular, the responsibility of nursing leadership and management for decision-making in the area of home care.

Acknowledgements

We want to thank Gullvi Nilsson and Monique Federsel for reviewing the English language.

Source of funding

The study has been supported by grants from the Research Council of Norway, ‘Chronic disease management – implementation and coordination of health care systems for depressed elderly persons’ (NFR, No. 2010/2242) and the Western Norway Regional Health Authority, Norway.

Ethical approval

No ethical approval was required for this paper.

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