Examining After-Hours Registered Nurse Leadership in Residential Aged Care Homes

The primary responsibility of registered nurses (RNs) in residential aged care homes (RACHs) is to provide safe and competent nursing care to residents. The increasing number of Australians entering older age leads to a rise in older adults entering RACHs, requiring higher-level care for chronic diseases and complex conditions. Currently, Australia's residential aged care beds are occupied daily by 180,000 permanent residents. Unfortunately, 60,000 deaths of residents in RACHs occur annually often due to adverse events that could be prevented of the many factors contributing to this are inadequate staffing ratios and skills shortages, particularly in the leadership roles of RNs. The Australian Royal Commission into Aged Care Quality and Safety noted that this could be prevented with better training and education of RNs in leadership roles in RACHs and higher staffing levels. 

Research has demonstrated that effective nurse leadership can improve quality of care, increase resident satisfaction, and reduce adverse events and complications. The challenges that present to nurses in the after-hours setting are quite different to those during day shifts, making this an area of interest. However, research on after-hours RACHs, particularly with RN leadership confidence and competence, is limited. This research study explores the concepts of leadership confidence and competence of RNs in the after-hours setting (3:00pm to 7:00am weekdays, weekends, and public holidays) in RACHs in Perth, Western Australia. 

This thesis will begin by comprehensively discussing these issues in the context of both national and international literature. In doing so, it will frame the overall aims and objectives of the study and justify the methodology and the theory used. A thesis map has been provided to orientate the reader to each chapter of this thesis. The purpose of the study was to identify ‘competence’ and ‘confidence’ of RNs working in RACHs after-hours when undertaking clinical leadership roles, and to examine impact of RN staffing after-hours on the incidence of adverse events for resident outcomes. The study used a quantitative approach with data collected throughout two phases in 10 RACHs in Western Australia: a cross-sectional survey of RNs working in RACHs, and a retrospective cohort analysis of adverse events data collected over a 3-month period. Quantitative data were analysed with the SPSS statistical software package. T-tests compared the actual difference between confidence and competence. To compare three or more variables, an analysis of variance (ANOVA) was used. The Self-determination theory (SDT) informed the selection of Clinical Leadership Competency Framework (CLCF), emphasizing shared leadership, teamwork, service management, setting direction, personal qualities and effective teamwork. The CLCF has been widely used across many clinical professions to build leadership awareness and guide leadership competencies across health service provision. 

RN respondents to the survey (n=100) in this study self-reported overall (90%) being confident or very confident in all domains of leadership, with highest confidence in managing services and lowest in setting direction. Resident records (n = 1560) of adverse events were collected from 10 RACHs with 1020 beds. An adverse event was reported on average, every second shift per home. During after-hour shifts (3:00pm-7:00am), but not day shifts (07:00am-3:00pm), having fewer nurses was associated with a likelihood of increased adverse events (specifically falls and pressure injury/skin tears). 

The findings of this study reinforce the Australian Royal Commission into Aged Care Quality and Safety recommendations regarding RN leadership in Australia’s health care system. The findings inform the strategic direction and help drive the necessary changes, through implementing evidence-based strategies to reduce adverse events and improve resident outcomes. The research highlights the ongoing issues of staff shortages and quality issues in RACHs particularly after-hours. It suggests providing RNs with professional development and mentoring opportunities, supported by RACH owners and management, and backed by well-defined policies to boost leadership confidence and competence. 

Enhancing training pathways for RNs is crucial for future leadership roles. Further research in various RACHs and organizations will necessitate examining adverse events that should consider staffing levels. The study suggests that future investigation and improvement in after-hours RN staffing could be beneficial.