Journal of Gerontological Nursing

PERCEPTION OF KNOWLEDGE: What Administrators and Assistants Know

Marcie Janz, MSN, FNP

Abstract

Health care for an aging population involves a growing demand for the long-term care services of home care agencies and nursing homes. As age increases, so does the incidence of chronic illness and disability (Almquist, 1980; Kane, 1984). For everyone over age 65 in a nursing home, there are at least two others who are homebound, 25% of whom are bedridden. Of the 95% of elderly at home, 46% over age 65 suffer limitations in activity (US National Center, 1979).

Many of the elderly remaining at home do so with family support, but when supplementary help is required, home care agencies provide personal care through nurse assistants. In nursing homes, where the most frail and disabled elderly reside, it is well documented that 80% to 90% of patient care is provided by nurse assistants (Almquist, 1980; Reagan, 1986; Waxman, 1984). Nursing's role in long-term care includes health maintenance and management of chronic conditions. Economic realities of health care, however, necessitate delegating many maintenance care needs of the elderly to nurse assistants. This includes such basics as nutrition, observing breathing and elimination patterns, skin integrity, and environmental safety.

Health management in long-term care necessitates a concern for the knowledge base of those providing basic needs to elderly. Nurse administrators responsible for the delivery of quality health care need to be aware not only of nurse assistants' training and competencies, but also how nurse assistants perceive the adequacy of their knowledge.

RESEARCH QUESTIONS

The purpose of this study was to investigate equality between nurse assistants' and nurse administrators' perceptions of information needed by nurse assistants in home care and nursing home settings. The research questions investigated were:

1. Is there a difference between the nurse assistants' perceptions and nurse administrators' perceptions of nurse assistants' need for knowledge?

Table

Age and education does not ensure improvement in nurse assistant knowledge. Nurse assistants could benefit from expanded nurse training programs that include not only physical needs of elderly, but also psychosocial and legal needs.

APPLICABILITY AND RECOMMENDATIONS

The knowledge base of nurse assistants is a major responsibility of nurse administrators in the delivery of quality care. Whether nurse assistants perceive their needs accurately, meeting actual learning needs in all aspects of elder care will continue to be important as the number of elderly increase. To do this, nurse administrators need the help of nurse educators with a sufficient gerontological background as well as a knowledge of government mandates. Facilities need coordinated training programs to include psychological caregiving skills and legal issues as well as physical care if not provided elsewhere. Inservice programs are then needed regularly to reinforce and supplement this training. Nurse administrators' awareness of knowledge could facilitate such programs.

The following are recommendations for further research based on the findings of this study:

* Separate replication of the study in nursing homes and home care settings to enhance the generalizability of the findings in these specific areas;

* Use of a larger sample to improve reliability estimates;

* Replication of the study to include a family/ client tool allowing feedback on observations of caregiving knowledge and skills; and

* Further research on knowledge perception of nurse assistants to help modify or enhance present training and inservice programs.

Nurse assistants provide the majority of basic care in long-term settings. For this care to be effective and safe, it is important for nurse administrators to be aware of the knowledge base of nurse assistants. Only when nursing develops, coordinates, and monitors the education and training of nurse assistants will elderly have the assurance of quality care in both home care and nursing home settings.…

Health care for an aging population involves a growing demand for the long-term care services of home care agencies and nursing homes. As age increases, so does the incidence of chronic illness and disability (Almquist, 1980; Kane, 1984). For everyone over age 65 in a nursing home, there are at least two others who are homebound, 25% of whom are bedridden. Of the 95% of elderly at home, 46% over age 65 suffer limitations in activity (US National Center, 1979).

Many of the elderly remaining at home do so with family support, but when supplementary help is required, home care agencies provide personal care through nurse assistants. In nursing homes, where the most frail and disabled elderly reside, it is well documented that 80% to 90% of patient care is provided by nurse assistants (Almquist, 1980; Reagan, 1986; Waxman, 1984). Nursing's role in long-term care includes health maintenance and management of chronic conditions. Economic realities of health care, however, necessitate delegating many maintenance care needs of the elderly to nurse assistants. This includes such basics as nutrition, observing breathing and elimination patterns, skin integrity, and environmental safety.

Health management in long-term care necessitates a concern for the knowledge base of those providing basic needs to elderly. Nurse administrators responsible for the delivery of quality health care need to be aware not only of nurse assistants' training and competencies, but also how nurse assistants perceive the adequacy of their knowledge.

RESEARCH QUESTIONS

The purpose of this study was to investigate equality between nurse assistants' and nurse administrators' perceptions of information needed by nurse assistants in home care and nursing home settings. The research questions investigated were:

1. Is there a difference between the nurse assistants' perceptions and nurse administrators' perceptions of nurse assistants' need for knowledge?

Table

TABLE 1Assessment of Nurse Assistant Learning Needs

TABLE 1

Assessment of Nurse Assistant Learning Needs

2. In what specific areas do nurse assistants and nurse administrators perceive that nurse assistants need additional information to be knowledgeable in care of elderly?

3. What is the relationship between the selected demographic variables of educational level and age in nurse assistants and the perceptions of need for additional knowledge?

METHOD

The subjects consisted of a stratified random sampling of nurse administrators from 21 nursing homes and 21 home care agencies in a Midwestern state, and three nurse assistants from each of these same facilities. Rural and urban facilities were represented, as well as proprietary and nonprofit agencies. The survey was conducted from June to September 1989 prior to the full implementation of Health Care Financing Adrninistration (HCFA) regulations on nurse assistant education.

Little relevant literature and the inability to find existing measurements of congruence necessitated an investigator-developed tool. This was a mailed questionnaire with a parallel form for each sample group. Demographics comprised the first part of the tool. The main portion consisted of 20 multiple choice questions on perceptions of need for additional information. The questions related to physical, legal, and psychosocial needs of the elderly. Response choices were no need for more knowledge, some need for more knowledge, or a great need for more knowledge (Table 1).

RELIABILITY AND VALIDITY

A new tool required a determination of validity and reliability. Internal validity was made by graduate faculty members from the University of Wisconsin, Oshkosh, and nurse administrators in long-term care. An eighth grade reading level was established based on Burke, D'Erosma, and Burger's model course of instruction for nurse assistants (Burke, 1980).

Reliability was established in a pilot study of four randomly selected nurse administrators from nursing homes and home care settings and 12 nurse assistants in the same facilities. The pilot response of 100% was computer checked with 0.9352 as alpha for the 20-item questionnaire.

DATA ANALYSIS

Nurse administrator response in the main study was 93% (18 nursing homes and 21 home care agencies). Table 2 provides a descriptive summary of the nurse administrator sample. The majority listed baccalaureate as the highest level of education. A master's in nursing was seen in eight responses (20.5%), six (15.4%) were diploma prepared, five (12.8%) were associate degree prepared, and two administrators held a baccalaureate degree in a non-nursing area. A lack of nurse assistant training programs was reported in 26 (66.7%) of the facilities. This is greater than the survey conducted by Kipp (1989), which found that 40% of facilities had no formal nurse assistant training program. Annual inservice programs ranging from three to more than 13 per year were reported by 92.3% of the facilities sampled.

Forty-two nurse assistants responded from nursing homes and 55 from home care agencies for a response rate of 77%. Table 3 is a demographic description of the nurse assistant sample. Home care assistants reported the greatest number in the over 50 age group, and the greatest longevity in a single facility. Education level of assistants ranged from ninth grade as the last completed grade to 12th grade plus 3 years. A majority, 67 (68.4%), of the respondents completed 12th grade, 8 (8%) had less than a 12th grade education, and 22 (22%) accomplished more than a 12th grade education with vocational or college classes. Seventy-nine (79%) of nurse assistants had attended inservice programs within 3 months prior to the survey. Nursing home assistants attended such recent inservice programs at a rate of 41.8%, whereas home care assistants' attendance was 2 (37.7%). Each research question was analyzed separately.

Table

TABLE 2Descriptive Characteristics of Nurse Administrators

TABLE 2

Descriptive Characteristics of Nurse Administrators

Difference Between Assistants' and Administrators' Perceptions of Need for Knowledge

The 20 questions of the instrument were placed in three scales: psychosocial needs of elderly, physical needs, and legal needs. Data for the first question was analyzed using the non-directional f-test. At a probability of .0001, a difference existed between nurse administrators' (mean response 40.77) and nurse assistants' (mean response 33.59) overall perception of need for additional knowledge. At a rate of 65.9%, nurse assistants saw no need for additional knowledge, whereas 34% of the administrators saw no need. Nurse administrators saw nurse assistants as needing some knowledge at a rate of 64%, whereas only 32.6% of assistants saw some need of knowledge. One percent of both groups saw a great need for knowledge, giving the only equality in nurse assistant and nurse administrator perceptions.

Table

TABLE 3Descriptive Characteristics of Nurse Assistant Sample

TABLE 3

Descriptive Characteristics of Nurse Assistant Sample

Difference in perceptions of need for knowledge may be related to what the literature identified as inadequately trained nurse assistants (Fisk, 1984; Norayanosomy, 1985; Stein, 1986). Where little training in basic concepts has occurred, nurse assistants may perceive their knowledge base as adequate whereas nurse administrators do not.

Specific Areas Where Assistants Need More Knowledge

The Figure examines the psychosocial, physical, and legal scales by total percentages of each response. Data analyzed by the nondirectional t-test indicated that nurse assistants felt they had more knowledge on care of the elderly than nurse administrators felt they had. In psychosocial areas, the mean percentage response for nurse assistants was 1.856, whereas nurse administrators responded at 2.101. In legal areas, the nurse assistant mean response was 1.703, whereas for administrators it was 2.092. In physical needs, a closer mean was seen with nurse assistants at 1.554 and nurse administrators at 1.995.

Perceptual differences in specific areas of psychosocial, physical, and legal needs may be due to two factors. The combination of nursing home and home care assistants may have affected scale responses. Although basic training is the same, job expectations can be diverse. Another factor addressed in literature is the lack of understanding a nurse assistant has of the role itself (Brown, 1988). Can nurse assistants understand the importance of supplying psychosocial needs in a task-oriented environment? If educational components in psychosocial needs are absent in training, nurse assistants may be unable to identify these needs while caring for elderly. A discrepancy of knowledge needs in legal areas may be due to inadequate sharing of information of federal and state regulations on the part of nurse administrators, as well as assistants' perceptions that such regulations apply only to administrative personnel.

Relationship Between Educational Level and Age

The Pearson product correlation was used to determine the relationship in research question 3. Based on a significance level of .05, no relationship was seen between the variables of age and education in any of the three scales for the 98 responding nurse assistants. Even though the tool had been piloted and reliability established, there may have been problems understanding some of the questions. A factor in this lack of significance may have been the variables themselves not reflecting a need for more or less knowledge, while other variables not examined in this study could have related better to knowledge need ( Woolf ork, 1989).

CONCLUSIONS

The availability of inservice programs and attendance by the majority of nurse assistants indicated that attempts at ongoing education of nurse assistants did occur. Sufficient information was being provided to nurse assistants in the study to cover great knowledge deficits as evidenced by the physical and legal scales (topics for state-mandated inservice programs in Wisconsin include resident rights, but not psychosocial issues). Present regulations mandating certification by preservice training of nurse assistants of no less than 75 hours, as well as the requirement of nurse assistant testing may today decrease knowledge deficits of nurse assistants in physical, legal, and psychosocial areas.

FIGUREExamination of Psychosocial, Physical, and legal UaIn by Total Percentages

FIGURE

Examination of Psychosocial, Physical, and legal UaIn by Total Percentages

Age and education does not ensure improvement in nurse assistant knowledge. Nurse assistants could benefit from expanded nurse training programs that include not only physical needs of elderly, but also psychosocial and legal needs.

APPLICABILITY AND RECOMMENDATIONS

The knowledge base of nurse assistants is a major responsibility of nurse administrators in the delivery of quality care. Whether nurse assistants perceive their needs accurately, meeting actual learning needs in all aspects of elder care will continue to be important as the number of elderly increase. To do this, nurse administrators need the help of nurse educators with a sufficient gerontological background as well as a knowledge of government mandates. Facilities need coordinated training programs to include psychological caregiving skills and legal issues as well as physical care if not provided elsewhere. Inservice programs are then needed regularly to reinforce and supplement this training. Nurse administrators' awareness of knowledge could facilitate such programs.

The following are recommendations for further research based on the findings of this study:

* Separate replication of the study in nursing homes and home care settings to enhance the generalizability of the findings in these specific areas;

* Use of a larger sample to improve reliability estimates;

* Replication of the study to include a family/ client tool allowing feedback on observations of caregiving knowledge and skills; and

* Further research on knowledge perception of nurse assistants to help modify or enhance present training and inservice programs.

Nurse assistants provide the majority of basic care in long-term settings. For this care to be effective and safe, it is important for nurse administrators to be aware of the knowledge base of nurse assistants. Only when nursing develops, coordinates, and monitors the education and training of nurse assistants will elderly have the assurance of quality care in both home care and nursing home settings.

REFERENCES

  • Almquist, E., Bates, D. Training programs for nursing assistants and licensed practical nurses in nursing homes. Journal of Gerontological Nursing 1980; 6:623-627.
  • Brown, M. Nursing assistants' behavior toward the institutionalized elderly. QRB 1988;14(1):15-17.
  • Burke, R., D'Erosmo, M., Burger, S. Research brief: Training geriatric nursing assistants - A solution. Journal of Long-Term Care Administration 1980; 15(9):37-41.
  • Fisk, V. When nurses' aides care. Journal of Gerontological Nursing 1984; 9:119-127.
  • Kane, R.L., Ouslander, J.G., Abross, LB. Essentials of clinical geriatrics. New York: McGraw Hill, 1984.
  • Kipp, B. New training requirements for nursing assistants and home health aides. Aging in the News 1989; 2(2):10-11.
  • Norayanosomy, S. Evaluation of a training curriculum for nursing assistants. Nurse Education Today 1985; 5:124-129.
  • Reagan, J. Management of nurses aides in long-term care settings. Journal of LongTerm Administration 1986; 14(2):9-14.
  • Stein, K.Z. Nursing assistants learn through the competency-bases approach. Geriatr Nurs 1986; 7:197-200.
  • United States National Center for Health Statistics. Current estimates from the national health interview survey: United States, 1979. Vital and Health Statistics, Series 10, No. 136. Washington, DC: US Government Printing Office, 1979. Department of Health and Human Services Publication No. (PH) 81-1564.
  • Waxman, H.M., Carner, E.A., Berkenstock, G. Job turnover and job satisfaction among nursing home aides. Gerontologist 1984; 24:503-509.
  • Woolfork, CH. Certified program for aides fosters professional growth. Geriatr Nurs 1989; 10:178-180.

TABLE 1

Assessment of Nurse Assistant Learning Needs

TABLE 2

Descriptive Characteristics of Nurse Administrators

TABLE 3

Descriptive Characteristics of Nurse Assistant Sample

10.3928/0098-9134-19920801-04

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