The Journal of Continuing Education in Nursing

Original Article 

Effective Factors for Development of Gerontological Nursing Competence: A Qualitative Study

Zahra Purfarzad, MSc, BSc; Masoud Bahrami, PhD, MSc, BSc; Mahrokh Keshvari, PhD, MSc, BSc; Mohammad Rafiei, PhD, MSc; Nina Sivertsen, PhD, RN; Grad Cert, Ed, BNg

Abstract

Background:

Many nurses working in hospitals are not prepared to provide appropriate care for older people. This qualitative study aimed to identify factors influencing the development of gerontological nursing competence in Iranian hospitals.

Method:

Twenty-six participants (nine nurses, 12 nurse managers, four clinical instructors, one physician) who worked in four teaching hospitals and nursing schools were interviewed by semistructured interview method. Conventional content analysis was used.

Results:

Two main categories emerged from the data: (a) management factors with the subcategories of meritocracy in elderly nursing, leadership style of nursing managers, educational system, the quality of working life, and performance management; (b) organizational factors with the subcategories of organizational learning, and organizational support.

Conclusion:

These findings can help nurse managers and clinical instructors identify, develop, and implement strategies for further development of gerontological nursing competence. [J Contin Educ Nurs. 2019;50(3):127–133.]

Abstract

Background:

Many nurses working in hospitals are not prepared to provide appropriate care for older people. This qualitative study aimed to identify factors influencing the development of gerontological nursing competence in Iranian hospitals.

Method:

Twenty-six participants (nine nurses, 12 nurse managers, four clinical instructors, one physician) who worked in four teaching hospitals and nursing schools were interviewed by semistructured interview method. Conventional content analysis was used.

Results:

Two main categories emerged from the data: (a) management factors with the subcategories of meritocracy in elderly nursing, leadership style of nursing managers, educational system, the quality of working life, and performance management; (b) organizational factors with the subcategories of organizational learning, and organizational support.

Conclusion:

These findings can help nurse managers and clinical instructors identify, develop, and implement strategies for further development of gerontological nursing competence. [J Contin Educ Nurs. 2019;50(3):127–133.]

Although demographic changes are varied in different parts of the world, population aging is a global phenomenon (World Health Organization, 2015). The elderly are the largest recipients of health care services in hospitals (Esterson, Bazile, Mezey, Cortes, & Huba, 2013). Nurses are responsible for providing care to elderly patients admitted to hospitals; in addition to the general nursing competencies, they must also posit gerontological nursing skills (Persoon, Bakker, van der Wal-Huisman, & Olde Rikkert, 2015).

In a global context, nursing education programs increasingly incorporate gerontological nursing in their curriculum (Deschodt, de Casterlé, & Milisen, 2010). However, many nurses have received little formal education or have not been trained in specialized practices (Esterson et al., 2013). Some studies indicate that nurses lack knowledge and skills about the care of older people (Baumbusch et al., 2017). Several studies have identified negative attitudes of nurses toward geriatric nursing and other work with older patients (Mansouri Arani, Aazami, Azami, & Borji, 2017). Evaluations of nurses in Iranian hospitals show that many nurses holding a bachelor's degree have not obtained any specialized education or professional development in the field of gerontological nursing (Ahmadi, Seyedin, & Fadaye-Vatan, 2015).

Recent research found a gap between the expected competencies and the competencies of the working, care-providing nurses. A necessary step to resolve such a challenge is to identify the barriers and enablers of gerontological nursing competence development. A review of the literature indicated that few studies have been conducted to investigate the factors affecting nursing competence in the care of the older patients. For example, Baumbusch, Leblanc, Shaw, and Kjorven (2016), conducting a study on the factors influencing the self-efficacy of nurses to care for older adults in Canada, pointed out the factors such as the unique and complex needs of the older adults, family's involvement in caring, organizational contexts, and social context. Yet, no study has been located identifying the factors influencing the development of gerontological nursing competence in Iranian hospitals.

The lack of standardized gerontological competence development in Iranian nursing standards gives impetus for undertaking this research. The factors influencing the development of gerontological nursing competence in Iranian sociocultural context are not clear, and quantitative research does not reveal the depth of existing reality. This study was conducted to identify factors that influence the development of gerontological nursing competence in Iranian hospitals.

Method

Design

This qualitative study was part of a nursing doctoral dissertation. The aim of this study was to identify factors influencing the development of gerontological nursing competence in Iranian hospitals. The overarching study was conducted using conventional content analysis. In this method, codifications and classifications are directly derived from raw data, and the researcher tries to gain new insights and a rich understanding of a phenomenon with the help of current raw data (Hsieh & Shannon, 2005).

Participants and Settings

Twenty-six participants (nine nurses, 12 nurse managers, four clinical instructors, one physician) who worked in four teaching hospitals and nursing schools affiliated with Arak, Isfahan, and Tehran Universities of Medical Sciences in Iran were chosen by use of purposive and snowball sampling. Table 1 provides demographics of the participants. Sampling began with the nurse managers and nurses, who worked more in the field of gerontological nursing care. Snowball sampling was also used in which the researcher asked participants to nominate other nurses who might be suitable and willing to take part in the study. The selection criteria required the participants to hold at least a Bachelor's degree, at least 6 months of clinical experience with older patients, and ability and willingness to express experiences with maximum diversity (i.e., job title, background and workplace, age, gender, and education level).

Participants' Characteristics (N = 26)

Table 1:

Participants' Characteristics (N = 26)

Data Collection

Data collection and analysis were conducted concurrently until theoretical saturation was achieved. In the current study, when no new category or data were obtained and after all categories were completed in the last four interviews, the interviews were stopped. The data of this study were collected from September 2015 to April 2016 using semistructured interviews. The duration of the interviews was 20 to 60 minutes. The location and the duration of the interviews were selected by the participants. Table 2 lists examples of interview questions.

Examples of Interview Questions

Table 2:

Examples of Interview Questions

Data Analysis

Data were concurrently analyzed during data collection, using the conventional content analysis method. The researcher (Z.P.) gathered an overall view of the interviews by listening to the recorded interviews, which were transcribed verbatim, several times. Then, the interview text was read word for word to highlight any words containing the key concepts; then, the codes were extracted. From extraction to labeling, these codes were reviewed in a continuous and consistent process. Similar codes were merged and categorized. They were then named according to the idea in each category (Graneheim & Lundman, 2004). To ensure rigor of the findings, extracted codes were checked and confirmed by three of the participants. Interviews were conducted by the principal researcher (Z.P.). However, checks by other two colleagues (M.B., M.K.) were conducted and agreement was achieved upon the codes and categories. To assure the dependability and confirmability of the findings, the inductive process of reaching from actual data to categories were recorded.

Ethical Considerations

The current study was approved by the Ethics Committee of Isfahan University of Medical Sciences and Arak University of Medical Sciences. First, the purpose of the study was explained to all participants. Permission was obtained from the participants to record their interviews. The participants were assured that their information, obtained through their interviews, would remain confidential, and that the results of the research would be published without mentioning their names. Thus, in reporting the results, the codes were presented. Informed consent was obtained from the participants to attend the study, to have an interview, and to have it recorded.

Results

Analysis of the interview data led to identification of two main categories and seven subcategories.

Management Factors

Meritocracy in Gerontological Nursing. Meritocracy means the selection of gerontological nurses based on merit and their empowerment. The participants stated that competencies of gerontological nursing need to be identified. Then, the selection criteria and the requirements for the gerontological nursing should be defined. In addition, gerontological nursing competencies should be taken into account at the time of selecting the staff, continuing education program, and performance management system. One participant stated:

The people, selected for gerontological nursing, need to pass some specific educational courses in gerontological nursing—the courses that teach such issues as how to communicate with the elderly and other issues related to the elderly.

Gerontological nursing competence was differentiated from general competence. Participants emphasized the need to develop national standards of gerontological nursing competence to guide competence development:

Gerontological nursing competencies are not defined… and we do not have a description of specialized tasks for gerontological nurses…. Most education programs are about the general competencies of nurses, and we do not have a program for gerontological competence development.

Educational System. Participants stated there are no ongoing and continuing education and orientation programs in the field of gerontological nursing: “We did not receive any special training in the field of aging at all….”

The majority of participants referred to the lack of effectiveness of electronic tests in their competence development. According to their experiences, test questions are not standardized, and there is no supervision of the proper implementation of the test. Also, educational content is provided only in writing, which reduces the effectiveness of electronic tests. Other barriers to competency development included the inadequate motivation for learning. Most participants considered the most important motivational factor for attending classes was to gain a retraining score. Some of them complained about time limitations, work overload, inappropriate schedules, and lack of the use of different teaching methods. One participant stated:

Classes and workshops are much better than electronic tests and educational booklets. I do not even read the booklet myself. But, workshops, which let nurses share their nursing experiences, can be very helpful. The class must somehow attract the staff.

Lack of evaluation for educational plan effectiveness and lack of giving a feedback to the nurses were expressed as other problems related to the educational system:

Educational programs are not evaluated well. It is important to check how effective the provided trainings were on the knowledge, attitude, and performance of the nurses.

The participants stressed the need for having a positive attitude toward old age and gerontological care as a part of gerontological nursing competence, stating that improving the affective domain should be part of nursing staff educational courses: “I am sure everything starts with people's beliefs…. We have to pay attention to this issue in our educational courses.”

Performance Management. According to the experiences of the participants, the dominant expectation of the care system from the nurses was focused on the technical aspects of care and work (task orientation), routine-centeredness, theoretical knowledge, documentation, and taking measures related to accreditation. One participant stated, “Nursing care has become just limited to giving the medication or doing the caring procedures, not even according to the standards…. It's not patient-centered; it is task-oriented.”

Lack of proper evaluation criteria for assessing the gerontological nursing staff performance, lack of specific tools for evaluating the nurses' performance based on gerontological nursing competencies, and nursing managers' nonexpectation of the nurses to have evidence-based practice in gerontological nursing were expressed as other problems related to performance management. One participant stated:

[The] educational supervisor should go over to the nurse who is working and ask him/her on the spot. It is very influential. Finding that they are being supervised, they will do their job more accurately. For example, at the very moment s/he goes to bedside, the supervisor should ask her/him some questions. Whether related to the job they are doing or any other procedures, their performance should constantly be supervised.

Leadership Style of Nursing Managers. According to participants' opinions, most nursing managers did not have sufficient competence in leadership. Participants emphasized the need for applying telling and supportive leadership styles for novices and low-qualified people. According to them, behaviors such as training, directing, supporting, controlling, and direct monitoring can be effective in competence development for novice nurses. One participant stated:

The new nurses coming here are not good nurses. You have to push them to do something. They do not really care about work. I would say that there is a lack of control on them. They should be inspected regularly. Someone who makes mistakes or is negligent should be severely dealt with.

According to participants' experiences, nursing managers who overlook the capabilities of nurses and emphasize the performing of tasks make nurses lose their motivation to develop competence. Providing negative feedback and the nursing managers' neglect toward establishing human communication were also identified as the most important deterrent factors in competency. One participant stated:

Inappropriate and negative feedback, especially in front of the patients, and offensive behaviors of the managers can affect our nurses' behavior and demotivate them…. Sometimes, I had no idea why my grading was down. Later on, I found out that our supervisor had a log book in which she would note our mistakes. But, she never gave us any feedback.

Participants emphasized the need to use leadership powers such as punishment, encouragement, and expertise, commensurate with the levels of nurses' readiness. According to participants' experiences, the leadership role of managers can create opportunities for the learning and development of gerontological nurses. Managers who act as role models are effective for the professional growth of gerontological nurses.

The role of a head nurse should not be limited to do his/her visit or do the job split. I think the teaching role is very significant here…. If you are a senior head nurse, when you go to your department, you should make your nurses expert first. See how expert they are at their work. Teach them what you yourself have received, and then ask them to do it at the bedside.

Quality of Working Life. The quality of working life is influenced by a lack of safety and job security, nursing managers' inappropriate and unproductive communication with the staff, lack of promotion opportunities, lack of decision-making power and professional independence of the nurses, lack of a balance between work and family responsibilities, the need for fair and adequate payment, performance reviews, less than satisfactory performance, lack of psychological comfort in the workplace, and the necessity of using capable managers. Quotations from the participants that highlight this subcategory included the following:

Sometimes a nurse looks sad and her face shows that she is suffering from something that prohibits her from relieving the suffering of others... Nurses are an oppressed stratum in hospitals and since they are oppressed, the empire power of a doctor makes the nurses' spirit weakened… There should be a difference between the one who works and the one who does not. This should surely be considered in their emolument and benefits.

Organizational Factors

Organizational Learning. Organizational learning was represented, with the subcategories of learning from others (i.e., sharing scientific knowledge and practical skills by use of the human capital, and learning from the patient and family); situational learning (i.e., learning in the face of the real situation); learning from errors (i.e., learning from the occurred or imminent mistakes or failures, error reporting, finding the root causes of errors, and sharing these learned points); learning through guidance tools (i.e., policies, manuals, and clinical guidelines and protocols in the hospital departments); and learning by reviewing, reporting, and correction of hospital committees' problems. In the participants' opinion, the presence of a professional gerontological nurse in each section can serve as a role model for the professional training and development of other nurses. It can also lead to the individual professional growth and improved nursing care quality. One participant stated:

Hospital committees that are held monthly can enhance the staff's competence in gerontological care…. For example…we implemented a system where errors were reported to all wards so that all the staff knew about the errors and staff's sensitivity increased.

Organizational Support. The participants stressed the need for organizational support in developing their competencies. They referred to such factors as the development of human resources on the basis of competencies; the supply of human resources, protocols, or clinical guidelines based on the evidence of gerontological nursing; a supportive and elderly-friendly organizational climate; and establishing an appropriate physical environment suitable for old age. The participants believed that although some measures have been taken in some cases, organizational support still needs to be improved. One participant commented:

Our department has no room for a handle…. The hand-rail is on the other side…. Imagine an elderly [person] wanting to go to the bathroom; there are just two pillars s/he can take as a help…. Our physical environment is not desirable for the elderly.

Discussion

The findings of this study enabled a more profound exploration of factors influencing the development of gerontological nursing competence in Iranian hospitals. Management and organizational factors all contribute to the development of competence around providing nursing care to older people.

The findings of this study showed that to develop competency, the main focus of human resource management should be on gerontological nursing competencies concerning the hospitalized elderly. Few studies exist on the development and evaluation of continuing education programs on gerontological nursing care. In those studies, the contents of the curriculum have been identified based on the key competencies of gerontological nursing, which have been accompanied with outcomes such as gerontological nursing knowledge development, positive attitude toward aging, and improvement of nurses' perceptions of gerontological nursing care (Baumbusch et al., 2017; Solberg, Solberg, & Carter, 2015).

Lack of awareness-raising and standard continuing education programs in the field of gerontological nursing was considered as the most important challenge in the hospital education system, which is in line with the findings of other studies (Ahmadi et al., 2015; Esterson et al., 2013). In Iranian hospitals, no special orientation programs for gerontological nursing, mentorship, and preceptorship exist to support and guide the novice nurses. On the other hand, senior nurses, who informally work for the support and education of junior nurses, receive no bonuses (Ebrahimi, Hassankhani, Negarandeh, Azizi, & Gillespie, 2016). So, one of the suggested strategies in this regard was empowerment of the qualified human forces in the field of gerontological nursing, such as mentors, preceptors, and professional gerontological nurses to help develop the competencies of other nurses, especially novice nurses.

In relation to knowledge transfer methods, most participants complained about the lack of various educational methods. In several studies, various educational methods have been adopted to improve the effectiveness of gerontological nursing continuing education programs (Baumbusch et al., 2017; Donahue, Kazer, Smith, & Fitzpatrick, 2011; Dubé & Ducharme, 2014). Weakness in evaluating educational programs and providing no feedback were identified as other existing problems affecting gerontological nursing competence. In the same vein, a study by Eslamian, Moeini, and Soleimani (2015) in Iran showed that the participants asked for periodical evaluation, supervision on evaluations, and administration of a pretest–posttest in all education sessions. Similarly, Johnson et al. (2016) in Australia showed that provision of feedback can be effective in improving nurses' performance.

Among the most important factors affecting the development of competence was lack of proper criteria and specific tools to evaluate specialized performance based on gerontological nursing competency. In a review of the literature, only the Hartford Institute in NYU College of Nursing developed a gerontological nursing competency tool for the RNs in hospitals to evaluate the management of gerontological syndromes (Purvis, Zupanc, VanDenBergh, & Martin, 2015). The participants suggested that some fundamental changes be made to the performance evaluation and clinical supervision systems. Of the most important suggestions in this regard were identification of evidence-based care policies and development of protocols and guidelines in gerontological nursing care; with those, nursing managers could use the appropriate criteria for assessing the performance of nurses to be more effective in clinical supervision. In line with the findings of the current study, nurses in the study by Boltz, Parke, Shuluk, Capezuti, and Galvin (2013) in the United States stated there was lack of evidence-based protocols and clinical guidelines for gerontological nursing.

According to the findings of the current study, the adaptability of leadership style of nursing managers with the level of nurses' readiness helps to develop gerontological nursing competence. In this regard, the situational leadership model, according to Hersey, Blanchard, and Johnson (2001), defines four leadership styles that leaders should choose according to the individual's level of readiness. In this case, the most appropriate leadership behavior can be selected for the staff.

In the current study, the identified motivational factors in the subcategory of quality of working life play a significant role in gerontological nursing competence development. Kim, Han, Kwak, and Kim (2015) found a positive and significant relationship between the quality of working life and clinical competence among Korean nurses. AllahBakhshian et al. (2017) in Iran raised concerns about the lack of an appropriate system for organizational growth and suggested there should be a reward and punishment system based on performance.

Organizational support was identified as another factor in gerontological nursing competence development. Wong, Ryan, and Liu (2014) wrote that organizational support for elderly-friendly care is considered as an organizational priority. Therefore, the management and leadership of the hospital must be committed to elderly-friendly care with the development of human resources, policies and procedures, care delivery processes, and physical spaces based on the needs of elderly patients. Also, the results of Baumbusch et al. (2016) in Canada emphasized the impact of organizational contexts on the readiness of gerontological nurses. Participants pointed out inconsistencies between the physical environment and the needs of the elderly, the need for experienced staff, the increase in nurse-to-patient ratio, and training and professional development in their study.

Limitations

This was a small-scale qualitative study conducted in four teaching hospitals and nursing schools affiliated with Arak, Isfahan, and Tehran Universities of Medical Sciences in an Iranian context. However, the authors conducted a purposive sampling with maximum variation and obtained a profound insight on an unknown concept that is performed in this environment for the first time. The findings may have transferability to other contexts.

Conclusion

Management and organizational factors all contribute to the development of competence in nursing older adults. To improve gerontological nursing and establish standardized gerontological competency markers, making some fundamental changes in human resource management is necessary. Development of gerontological nursing competency requires a holistic approach, defining the qualifying conditions and competency-based selection, competency-based education, feedback, development and implementation of specific evaluation tools, and knowledge management and information sharing. Continuous performance evaluation and developing guidelines and protocols for care are essential.

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Participants' Characteristics (N = 26)

CharacteristicValue
Job status, n
  Nurse9
  Head nurse8
  Clinical supervisor2
  Educational supervisor1
  Head of nursing office of the hospital1
  Clinical instructor4
  Physician1
Education level, n
  Bachelor's degree13
  Master's degree5
  Master's student3
  PhD candidate4
  Doctoral1
Gender, n
  Female22
  Male4
Work experience (years), range1–25
Age (years), range23–48

Examples of Interview Questions

What factors can influence the development of gerontological nursing competence in hospitals? What barriers have you experienced while learning gerontological nursing competence in hospitals? What strategies would you recommend for the development of gerontological nursing competence? What were the most important challenges you experienced in gerontological nursing? Please describe the most important events that helped you develop your competence in gerontological nursing? What do you suggest for improvement of gerontological nursing competence programs? In your experience, what factors acted as prohibitors or facilitators in improvement of appropriate gerontological nursing?
Authors

Ms. Purfarzad is PhD nursing student, Student Research Committee, Dr. Bahrami is Associate Professor of Nursing, Nursing and Midwifery Care Research Center, and Dr. Keshvari is Assistant Professor of Nursing, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; Dr Rafiei is Associate Professor of Biostatistics, Department of Biostatistics and Epidemiology, Arak University of Medical Sciences, Arak, Markazi Province, Iran; and Dr. Sivertsen is Lecturer, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.

This study is part of the doctoral thesis of the first author at Isfahan University of Medical Sciences, conducted as a joint thesis with Arak University of Medical Sciences.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank all participants for their valuable experiences.

Address correspondence to Masoud Bahrami, PhD, MSc, BSc, Associate Professor of Nursing, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, P.O. Box 81746-73461, Isfahan, Iran; e-mail: bahrami@nm.mui.ac.ir.

Received: April 04, 2018
Accepted: October 22, 2018

10.3928/00220124-20190218-08

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