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Experiences of registered nurses as managers and leaders in residential aged care facilities: a systematic review.

BACKGROUND: The phenomenon of an ageing population is being experienced globally, as countries struggle to change and improve residential models of care and provide services to the elderly. The role of the registered nurse (RN) is considered crucial to the clinical governance and management of care given. To date, however, no systematic review has examined the RN's experience in leadership and management.

OBJECTIVES: The objective of this review is to critically appraise, synthesise and present best available evidence on the experiences of RNs as clinical leaders and managers in residential aged care facilities.

INCLUSION CRITERIA: This review considered qualitative research papers that addressed the experiences of RNs as clinical leaders and managers in residential aged care facilities. Participants of interest were RNs, nurse leaders, nurses holding registration and or regulation under a board of nursing, nurses working in residential aged care and long-term care facilities. The diversity and use of language to describe nurses' roles and models of care for the elderly care environment were considered in the review.

SEARCH STRATEGY: The search strategy sought to find both published studies and papers, limited to the English language and published between January 1997 and February 2011. An initial limited search was done in Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index to Nursing and Allied Health Literature databases to identify the key words contained in the title or abstract and index terms used to describe the relevant terms in the article. A second extensive search was undertaken and extended to other relevant databases using all identified keywords and index terms. The third step involved searching reference lists and bibliographies of chosen articles for additional studies.

METHODOLOGICAL QUALITY: Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using an appropriate critical appraisal instrument from the System for the Unified Management, Assessment and Review of Information package. As both reviewers were in agreement on all studies included, a third reviewer was not required.

RESULTS: A final total of eight papers, qualitative in nature, were included in the review. The majority of papers examined the experiences of nurses' leadership styles and the management characteristics within their organisations. The qualitative papers were analysed using The Joanna Briggs Institute-Qualitative Assessment and Review Instrument.The process of meta-synthesis embodied in this programme involves the aggregation or synthesis of findings or conclusions. Five syntheses were derived with key themes related to education, professional nursing development, positive attitudes to aged care and the need for a supportive environment.

CONCLUSION: Nurses that work in the aged care environment show a strong motivation to work in care and provide the best outcomes in nursing the elderly. Geriatric nursing is considered a specialised and complex area of healthcare by the nursing profession. Nurses experience a lack of professional support and collaboration from allied health and medical colleagues. There is a lack of specific education that is focused in clinical leadership and health team management. There is no current structured pathway of learning and development for nursing careers in aged care. Nurses identify with their leadership role in residential aged care, and experience paradoxical feelings of being valued by the clients and devalued by the system at the same time. Organisational barriers are strong in preventing continuing education and skills development for nurse leaders in aged care environments.

IMPLICATIONS FOR PRACTICE: Overall the themes presented in the review reported the negative experiences of nurses in residential aged care and geriatrics. Nurses will continue to be devalued if there is no professional identity and support for their roles and need to have a career pathway when making the decision to enter into aged and geriatric practice. Clinical leadership training is needed for nurses to transition through practice into specialised roles such as the RN team leader and Geriatric Nurse Practitioner (GNP). Providing a career structure and choice in the industry for the nurse to become a clinical leader or a manager of health services will improve recruitment and retention. IMPLICATION FOR RESEARCH: More research is needed to identify the skills gaps experienced by nurses in aged care and geriatric care. This research could lead to the design and implementation of a skills audit to identify candidates for specialised courses so that clinical leadership and governance in aged care are improved. More research is needed for role construction and the professional development of the GNP. Organisations can benefit from research currently being conducted on the role of the RN in aged care and geriatrics, by mapping the skills mix of candidate RNs to the key performance indicators in the role. Organisations must change their perception and value of RNs as clinical leaders in care teams.

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