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