Discussion: Gerontological Nursing

Geriatric Nursing xx (2015) 1e7 Contents lists available at ScienceDirect Geriatric Nursing journal homepage: www.gnjournal.com Feature Article Future distinguishing competencies of baccalaureate-educated registered nurses in nursing homes Ramona Backhaus, MSc a, *, Hilde Verbeek, PhD a, Erik van Rossum, PhD a, b, Elizabeth Capezuti, PhD, RN, FAAN c, Jan P.H. Hamers, PhD, RN a a Department of Health Services Research, CAPRHI School for Public Health and Primary Care, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands b Zuyd University of Applied Sciences, Research Centre on Autonomy and Participation, P.O. Box 550, 6400 AN Heerlen, The Netherlands c Hunter College, City University of New York, Brookdale Campus West, Room 526, 425 E. 25th Street # 925, New York, NY 10010, USA a r t i c l e i n f o a b s t r a c t Article history: Received 16 April 2015 Received in revised form 18 June 2015 Accepted 22 June 2015 Available online xxx In view of the likelihood that the complexity of care required by those admitted to nursing homes will continue to increase, an expert consensus study was conducted to reach consensus on the competencies which distinguish baccalaureate-educated registered nurses from other nursing staff working in nursing homes. Thirty-one international experts, identified through literature and our professional network, participated in a two-round web-based survey and an expert meeting. Experts reached consensus on 16 desirable competencies, including some not traditionally associated with nursing expertise e.g. being a team leader, role model and coach within the nursing team. These findings suggest that revision of current nursing curricula, nurse training programs and nursing home job profiles might be needed to meet the medically and psychologically complex needs of nursing home residents. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Competencies Registered nurses Nursing homes Introduction Worldwide, the aging of the population will increase demand for long-term care services.1,2 Older adults want to stay at their own homes as long as possible, so only the most frail and dependent residents enter nursing homes.3,4 In the future nursing homes will not only have to grapple with higher demand for services and the increasingly complex needs of residents, but also with significant workforce shortages and poorly trained staff.2 The role of nursing staff is likely to become more complex as there is a trend to offer residents more personal choice, the diversity of care options is increasing and technological innovations continue.5 Future nursing home employees are likely to work with robotic care providers making continuous use of new electronic monitoring and decision-making systems.5 In addition to the shift to home and community based care for long-term living and support, other significant changes are occurring in health care systems worldwide that are influencing the resident population in nursing Conflict-of-interest statement: The authors declare no conflicts of interest. * Corresponding author. Maastricht University, Faculty of Health, Medicine and Life Sciences, CAPHRI School for Public Health and Primary Care, Department of Health Services Research, P.O. Box 616, 6200 MD Maastricht, The Netherlands. Tel.: þ31 43 3882456. E-mail address: r.backhaus@maastrichtuniversity.nl (R. Backhaus). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.06.012 homes.5,6 First, an increase in the use of sub-acute care for short term rehabilitation (v. medical-surgical or rehabilitation hospital) is resulting in more residents with acute needs and an increase in the flow of residents in and out of the nursing home.7 Second, long-stay residents are most likely to have moderate to severe dementia.8 Other changes are country-specific. For example in the United States (US), there is a growth in accountable care organizations (ACOs) requiring nursing homes to be preferred partners in health systems as well as an increased focus on nursing home quality benchmarks.5,9 In the Netherlands, nursing home care is increasingly organized in small-scale and homelike environments, especially for people with dementia, in which nursing staff have integrated tasks.10

These changes demand explicit competencies of highly-skilled staff. Recent evidence suggests that an increase in baccalaureateeducated registered nurses (BRNs) leads to better quality of care (QoC) in hospitals,11 but the impact on nursing home care is less clear.12,13 We opine that an increase in the proportion of BRNs would lead to an improvement in quality of life and QoC for nursing home residents. We assume that BRNs in nursing homes, similar to BRNs in hospitals, may be better able to deal with the more complex care needs and could supervise less educated staff. However budget constraints have meant that there are few registered nurses (RNs) working in nursing homes and little is known about their unique contribution to QoC.14 2 R. Backhaus et al. / Geriatric Nursing xx (2015) 1e7 the findings of this survey with the expert panelists. Third, a final survey was completed by the expert panelists, aimed to determine the degree of consensus on the future distinguishing competencies of BRNs working in nursing homes.

As in many countries few RNs hold a baccalaureate degree, BRNs are an especially scarce resource in nursing homes, so obtaining more information on how to allocate them in nursing homes is desirable. Understanding how best to allocate BRNs depends on reaching a consensus on the competencies, i.e. skills, knowledge and attitudes, which will, in future, distinguish BRNs from other nursing staff. An understanding of what distinguishes BRNs from other nursing staff would help nursing home administrators to make informed decisions about human resource allocation15 and could also inform future BRN educational programs. When reviewing current competency profiles, we found that information was lacking on specific competencies for BRN in nursing homes, although worldwide, a tremendous amount of BRN competency profiles exists. For example in the US, there are more than 600 registered nurse to bachelor of science in nursing (RN-BSN) programs alone.16 However, BRN competency profiles in the US are often based on a general profile, the American Association of Colleges of Nursing (AACN) Essentials,17 not mentioning settingspecific (i.e. nursing home) competencies for BRNs. We identified only four existing BRN-specific competency profiles18e21 that are focusing on the care for older adults (Table 1). Although different nurse competency profiles for dementia care exist, none specifically addresses BRNs.22 Only few profiles exist that focus on the nursing home setting, for example the “Nursing home culture change competencies for nurses”.23 Distinguishing profiles for BRNs are missing. Discussion: Gerontological Nursing

The aim of this study was to obtain insight into the competencies, which should in the future, distinguish BRNs from other nursing staff (e.g. registered nurses or licensed nurses) in nursing homes. As nursing home systems develop5,24 it is important to ensure that BRNs are equipped with competencies that will enable them to meet future demands. The expert panel Forty-one experts from various countries were identified through a literature search and our professional network. We defined an expert as an academically qualified person experienced in institutional long-term care and having expertise in the current work of BRNs in nursing homes in his or her country. We did not include BRNs since they would likely be influenced by their current working conditions and thus would have trouble envisioning alternative views of staff allocation. All identified experts were invited to participate in the consensus study. Survey on future tasks and distinguishing competencies of BRNs in nursing homes The survey was developed by our research team, who are all researchers in geriatrics. The survey had five parts. Part 1 asked about background information (age, gender, etc.). Part 2 consisted of questions on the current pattern of employment of BRNs in nursing homes (proportion of nursing home staff who are BRNs, current responsibilities of BRNs in the nursing home context). Part 3 was designed to elicit the respondent’s opinions about the future of nursing homes, including opinions about the minimum and ideal proportion of nursing home staff that should be bachelor-educated in 2030. In Part 4 the respondent described how he or she foresaw the responsibilities of BRNs in nursing homes in 2030, by answering questions such as “In your opinion, how much time will bachelor-educated registered nurses working in nursing home wards/ units (in your country in the year 2030) in general spend on clinical responsibilities?”. Part 5 asked the respondent to list 3e5 competencies specific to BRNs which he or she believed would be important in the nursing home context in 2030. Answering the questions in Parts 2 through 4 was intended to prompt the respondent to consider the competencies that should in future distinguish BRNs from other nursing staff. Method We conducted an expert consensus study to obtain insight into the competencies which should, in the future, distinguish BRNs from other nursing staff. The study consisted of three different steps. First, a survey on future tasks and distinguishing competencies of BRNs in nursing homes was completed by expert panelists. Second, an expert meeting was held to discuss and interpret Table 1 Overview of limitations of existing BRN competency profiles for the care of older adults. Name of the BRN competency profile Country/Year Developed by Specific for nursing home setting Distinguishing competencies of BRNs from other nursing staff Future-relevancy explicitly mentioneda Broad overview of competenciesb Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults18 Competencies for the RN to deliver person-centered long-term care19 Baccalaureate Gerontological and Geriatric Nursing Competence Profile20 Working areas of academically qualified registered nurses21 United States/2010 American Association of Colleges of Nursing/ Hartford Institute for Geriatric Nursing e e U U Canada/2012 Discussion: Gerontological Nursing

Research group (McGilton et al) e e U e The Netherlands/2012 Working group (members from educational and health care organizations) German Nursing Council/German Society of Nursing Science e e U U U U e e a b Germany/2014 Considering changes that are occurring in health care systems. i.e., not restricted to a specific area of expertise. R. Backhaus et al. / Geriatric Nursing xx (2015) 1e7 All participating experts received an e-mail with a link to the digital survey which was implemented using the online survey tool Surveymonkey (http://www.surveymonkey.com). One researcher (RB) made a list of all competencies mentioned by the experts. The research team evaluated this initial list and deleted repetitions and combined similar competencies to eliminate redundancy. Next, the research team discussed all competencies and clustered them, based on their content, into 4 themes: leadership and coaching; communication; evidence-based practice; client assessment and geriatric expertise. Expert meeting to review the future distinguishing competencies mentioned by experts The experts who had completed the survey were invited to participate in an expert meeting, to discuss the analysis and interpretation of the survey results, paying particular attention to the competencies which would, in the future, distinguish BRNs from other nursing staff in nursing homes. The expert meeting was held during the November 2014 annual scientific meeting of the Gerontological Society of America. The two-hour discussion was led by a moderator (EvR) and two co-moderators (EC; JPHH). The discussion was audiotaped (and subsequently transcribed) while two other members of the research team (RB; HV) took contemporaneous notes. Our analysis and the clustering into the 4 themes were discussed during the expert meeting. In addition, we asked which of the competencies on the list generated from the survey would really distinguish BRNs from other nursing staff with respect to each individual theme. Thinking about the specific contribution of BRNs to the care provided in nursing homes in the future helped the experts to answer these questions. Final survey to determine the degree of consensus on the future distinguishing competencies The list of distinguishing competencies, discussed and revised during the expert meeting, was presented in the final survey. Discussion: Gerontological Nursing

Experts who completed the first survey received an e-mail with a link to the digital survey which was, again, implemented using the online survey tool Surveymonkey (http://www.surveymonkey. com). The experts were asked to assess each competency for application as a future role specific to BRNs in nursing homes. In line with other research we considered that consensus had been reached on a competency when there was at least 75%25,26 agreement among the experts. Based on a discussion during the expert meeting we also included five short questions about the (future) employment of master-educated registered nurses (advanced nursing roles such as nurse practitioners) in nursing homes in the survey. Ethical considerations The Medical Ethics Review Committee (METC) of the Atrium Medical Centre (METC Atrium-Orbis-Zuyd) approved the study protocol (METC number 14-N-97). Participation in the study was voluntary. Participants were informed that their answers would be treated as strictly confidential and no identifying information about participants was collected. Participants in the expert meeting provided written informed consent to participation. 3 Results Thirty-six experts agreed to participate in the survey study; 31 completed the initial survey (86%) and 28 (78%) completed both surveys. Five experts participated in the expert meeting. Initial survey on future tasks and distinguishing competencies of BRNs in nursing homes Twenty-four of the 31 experts who responded to the initial survey were women. The mean age of survey respondents was 51 years (range: 39e66 years) and 27 were registered nurses. The experts came from four different continents (North America, Europe, Asia and Australia) and 14 different countries: United States (6), Canada (2), Germany (4), the Netherlands (4), Belgium (2), Sweden (2), Norway (1), Finland (1), Switzerland (1), United Kingdom (1), Spain (2), Australia (2), South Korea (2) and Taiwan (1). In most countries only a small proportion of nursing staff in nursing homes were BRNs. Across our sample as a whole the average proportion of nursing home nursing staff with a bachelor degree was 17% (range across countries: 1e70%). On average, experts thought that by 2030 at least 39% (range: 10e100%) of the nursing staff in nursing homes should be bachelor-educated, and suggested that ideally this proportion should be 53% (range: 15e100%). Experts thought that in the future BRNs would spend a similar proportion of their time on clinical responsibilities (e.g. skilled nursing procedures) but less time on managerial responsibilities (e.g. supervision, staffing the ward/unit) and more time on specialist responsibilities (e.g. staff education, care innovation, quality management). The experts identified 118 competencies distinguishing BRNs from other nursing staff. Discussion: Gerontological Nursing

After eliminating redundancies this was reduced to a list of 38 competencies (see Table 2). Eighteen competencies were related to leadership and coaching, 3 to communication, 7 to evidence-based practice and 10 to client assessment and geriatric expertise. Frequently mentioned competencies included “being a leader on the ward/nursing unit,” “being a staff and family coach/mentor,” or “able to evaluate the situation of a client in its entirety.” Our experts stressed that references to ‘leadership’ were not related to formal leadership positions, but to informal leadership as a role model and coach. Expert meeting to review the future distinguishing competencies mentioned by experts The participants of the expert meeting came from four different countries: United States (2), Canada (1), the Netherlands (1), and Switzerland (1). During the expert meeting the clustering into the 4 themes was presented and discussed. From the list of 38 competencies, some competencies were discussed as being too general to be considered as distinguishing competency. Examples are “being strategically and politically engaged,” “effective use of information technology,” and “international exchange of ideas” (see Table 2). In addition, the experts suggested to revise the definitions of some competencies (see Table 2): for example, the competency “highly skilled in communication” was revised to “All staff should be highly skilled in communication, but the BRN should be able to handle the more complex and challenging communication as well.” Based on the feedback from the experts, the research team reduced the list to 19 competencies. The experts stressed that the competencies that distinguish BRNs from other nursing staff would depend partly on the context. Some competencies would only be relevant to specific settings (e.g. small-scale units, sub-acute rehabilitation etc.). The experts stressed that successful implementation of innovations in care 4 R. Backhaus et al. / Geriatric Nursing xx (2015) 1e7 Table 2 Future distinguishing competencies of BRNs in nursing homes. Results of survey: 38 competencies Revised results expert meeting: 19 competencies Results of final survey: 16 competencies Leadership and coaching (18)  Outstanding interpersonal, cooperation, coordination and relationship-building skills  Able to establish a working relationship with the client  Ability to educate clients, family members and nurse staff (e.g. in terms of chronic illness management, self-management, health management and prevention)  Being a staff and family coach/mentor  Being a leader on the unit/ward (team leadership)  Person-centered leadership skills  Clinical leadership skills  Supervision skills  Handling team approaches and team models of care  Being a role model and coach within the nursing team Discussion: Gerontological Nursing

 Able to collaborate effectively with staff from other disciplines in the nursing home  Assisting the team to deliver client-centered care  More abstract and systems thinking skills (e.g. understanding nursing homes and their role within the overall health care system, seeing nursing practice as both individual and group work)  Critical reflective skills (to identify areas for improvement in care and support, as well as self-reflection skills to improve own professional practice)  Creativity to find and test new models of care as well as achieving support and autonomy to implement and evaluate such  Being strategically and politically engaged Discussion: Gerontological Nursing

 Able to manage the social and health resources to which nursing staff have access effectively  Able to coordinate the multidisciplinary team Communication (3)  Highly skilled in communication  Effective inter- and intra-professional communication  Effective use of information technology Leadership and coaching (9)  Being a team leader, role model and coach within the nursing team (no management leadership position)  Being a family coach/mentor  Able to create a working relationship and collaborate effectively with nursing home staff from other disciplines  Able to coordinate the multidisciplinary team: BRN is the professional who sees the whole picture, should organize regular team meetings in which all disciplines participate; should manage the overall care coordination (if e.g. physiotherapist says …Discussion: Gerontological Nursing