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Bing Jonsson2014

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48 views14 pages

Bing Jonsson2014

Uploaded by

Amelia Waliman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ORIGINAL ARTICLE

Competence in advanced older people nursing: development of ‘Nursing


older people – Competence evaluation tool’
Pia Cecilie Bing-Jonsson MSc, RN
PhD Candidate, Department of Nursing Science, University of Oslo, Oslo, Norway

Ida Torunn Bjørk PhD, RN


Professor, Department of Nursing Science, University of Oslo, Oslo, Norway

Dag Hofoss PhD


Professor, Department of Nursing Science, University of Oslo, Oslo, Norway

Marit Kirkevold RN, EdD


Professor, Department of Nursing Science, University of Oslo, Oslo, Norway

Christina Foss PhD, RN


Professor, Department of Nursing Science, University of Oslo, Oslo, Norway

Submitted for publication: 2 October 2013


Accepted for publication: 11 February 2014

Correspondence: BING-JONSSON P.C., BJØRK I.T., HOFOSS D., KIRKEVOLD M. & FOSS C. (2015) Competence in
Pia Cecilie Bing-Jonsson advanced older people nursing: development of ‘Nursing older people – Competence
Department of Nursing Science
evaluation tool’. International Journal of Older People Nursing 10, 59–72. doi: 10.
University of Oslo
1111/opn.12057
P.O. Box 1130
Blindern, Oslo
Norway Background. Community care is characterised by a move from institutionalised to
Telephone: +4797977920 home-based care, a large patient population with comorbidities including cognitive
E-mail: p.c.bing-jonsson@medisin.uio.no failure, and nurses who struggle to keep up with their many competence demands.
No study has examined the competence of nurses based on present demands, and an
instrument for this purpose is lacking.
Aim and objective. We conducted a Delphi study based in Norway to develop the
substantial content of a new competence measurement instrument. We sought to
reach consensus regarding which nursing staff competence is most relevant to meet
the current needs of older patients.
Design and method. A total of 42 experts participated in three consecutive panel
investigations. Snowball sampling was used. The experts were clinicians, leaders,
teachers, researchers and relatives of older people who required nursing. In Round
1, all experts were interviewed individually. These data were analysed using
meaning coding and categorisation. In Rounds 2 and 3, the data were collected
using electronic questionnaires and analysed quantitatively with SPSS.
Results. The experts agreed that health promotion as well as disease prevention,
treatment, palliative care, ethics and regulation, assessment and taking action,
covering basic needs, communication and documentation, responsibility and
activeness, cooperation, and attitudes towards older people were the most
relevant categories of competence.

© 2014 John Wiley & Sons Ltd 59


P.C. Bing-Jonsson et al.

Conclusions. The experts showed clear consensus regarding the most relevant and
current competence for nurses of older people. Assuming that older people in need
of health care have the same requirements across cultures, this study’s findings could
be used as a basis for international studies.
Implications for practice. Those who nurse older people require competence that is
complex and comprehensive. One way to evaluate nursing competence is through
evaluation tools such as the Nursing Older People – Competence Evaluation tool.

Key words: advanced nursing of older people, community care, competence


measurement, home care, nursing staff, professional competence

even under moderately conservative assumptions. Europe has


What does this research add to existing an increasingly frail older patient population characterised by
knowledge in gerontology? comorbidities, the use of polypharmacy and cognitive failure


(Boerma, 2006; Selbæk, 2008; Pedersen & Kolstad, 2009;
Nursing staff should be required to have advanced
Gautun & Hermansen, 2011). These effects demand increas-
comprehensive competence to meet the current needs
ingly advanced nursing competence in geriatrics, psychiatry,
of older patients.

psychology, pharmacology, communication and ethics (Ald-
Nursing staff should be competent with regard to
ridge-Bent, 2011; Fur aker, 2012). As in the rest of Europe,
health promotion and disease prevention, treatment,
the Norwegian government expects its nurses to have
palliative care, ethics and regulation, assessment and
additional advanced competence in interprofessional cooper-
taking action, covering basic needs, communication
ation, multicultural understanding, medical management,
and documentation, responsibility and activeness,
research facilitation, evidence-based practice and new tech-
cooperation, and attitudes towards older people.
nology application (Boerma, 2006; Norwegian Ministry of
What are the implications of this new Health & Care Services, 2010, 2011a,b). Whether this
knowledge for nursing care with older competence is present among clinical nurses of older people
people? is unknown (Johansen & Fagerstrom, 2010). We do know,
however, that, despite efforts to enhance the quality of
• Competence must be developed to reach the required
community health care, many reports exist of inadequate
advanced levels among nurses of older people.
health care in terms of unmet needs, adverse events and other
• These competence demands must be considered when
threats to care quality (Boerma, 2006; Sørbye et al., 2009).
hiring new nurses for older people.
Obviously, professional competence is a key issue when
providing quality healthcare services (McPherson et al.,
How could the findings be used to influence
2001). Quality of care requires that all people who deliver
policy or practice or research or education?
patient care and treatment possess the competence needed to
• It is unknown whether nursing staff have the compe- meet complex healthcare demands (Randolph et al., 2012).
tence required to meet the needs of older patients. However, an evaluation of the nurses who care for older
• Large-scale competence assessments are necessary to people in European countries provides a bleak but consensual
examine the status of nursing staff competence with picture: to a large extent, services are provided by assistants
regard to current job demands. with limited training, and few skilled staff members are
employed (Romøren et al., 2011; Angermann & Eichhorst,
2012). Consequently, a gap exists between the competence
expected of nursing staff and the workforce employed to
deliver care; the call for the need to measure clinical
Introduction
competence among nurses is appropriate (Benner et al.,
This article presents the development of a questionnaire to 2010). Evaluating nursing staff competence is of great
measure nursing staff competence in older people nursing. importance (Boerma, 2006; Colombo et al., 2011) because
According to the European Commission’s Ageing Report this assessment would provide an understanding that is vital
(2012), future demands for long-term care are substantial for the development of strategies to enhance competence,

60 © 2014 John Wiley & Sons Ltd


Competence measurement

thereby improving the quality of care (Donabedian & of context (Cowan et al., 2007). By specifying context (i.e.
Bashshur, 2003; Baker et al., 2006). how a nurse handles a particular nursing situation), one
A recent systematic literature review of the instruments might be more inclined to measure competence than perfor-
available for measuring community healthcare competence mance. In a literature review, Watson et al. (2002) concluded
(Bing-Jonsson et al., 2013) found that these instruments were that competence is a vague and ill-defined concept. However,
of insufficient conceptual, methodological or both types of in a follow-up literature review 10 years later, Yanhua and
quality, or they focused on aspects of community health care Watson (2011) claimed that progress towards consensus and
other than older people nursing. In line with recent develop- clarity regarding this concept is emerging, and this consensus
ments and the scarcity of research concerning nursing staff in seems to revolve around an understanding of competence as a
Norwegian community health care (Johansen & Fagerstrom, holistic construct.
2010; Bing-Jonsson et al., 2013), this paper explores the On a philosophical level, sound concept development is a
nursing competence related to caring for older people. This critical task in any effort to develop theory. Nurses must
study sought to identify the competence that is necessary to develop a conceptual repertoire that will do justice to the
provide safe and sound services to older people in need of phenomena within its domain (Risjord, 2010). Rodgers
home- or institution-based health care. We used the Delphi argued, ‘Concept development must be an on-going process,
method to develop the substantial content of a new compre- with no realistic end point. As phenomena, needs and goals
hensive instrument called ‘Nursing Older People – Compe- change, concepts must be continually refined and variations
tence Evaluation Tool’ (NOP-CET). Our research question introduced to achieve a clearer and more useful repertoire’
was what competence do community-based nursing staff (2000, p. 82). In this light, consensus regarding the definition
need to provide safe and sound healthcare services that meet of competence is not the issue. The realisation that research-
the current needs of older patients? ers must be explicit about their understanding of competence
and the acceptance that research will unearth new dimensions
of the concept (rather than support one’s initial understand-
Conceptualisation of competence
ing) are central to this issue. Like Eraut (1994), we define
The manner in which one conceptualises competence has nursing competence as contextual, which implies that com-
implications for the manner in which one examines the petence expectations should be stated in specific and contex-
concept. Competence has several meanings in the literature; a tual terms. For analytical purposes, competence can be
common understanding is linking competence to perfor- divided into knowledge, skills and personal attributes; in
mance. Another understanding is that being competent equals practice, however, these dimensions of competence are
being ‘adequate but not excellent’ (Eraut, 1994); this nursing interconnected. Technical, political and structural factors
science definition originates from Benner’s (1984) theoretical influence competence; thus, nursing competence is in a state
framework ‘novice to expert’. Three main research traditions of flux caused by the changing needs of patients and the
can be distinguished with regard to competence during the composition of personnel.
postwar period (WWII) (Cowan et al., 2007; Garside &
Nhemachena, 2013; Pijl-Zieber et al., 2014).
Method
The first research tradition concerns behaviour and the
skills that constitute satisfactory performance. This tradition
Design
employs typical techniques such as job and skills analyses
(Eraut, 1994). Critics have indicated that this tradition We explored competence in nurses who care for older people
neglects social and political dimensions of competence and using the Delphi method. This technique provides a way to
that it has treated the process of competence measurement as obtain expert opinions in a systematic manner (Irvine, 2005;
a purely technical matter. The second understanding of Waltz et al., 2005; Jirwe et al., 2009; Keeney et al., 2011).
competence includes cognitive and affective aspects as well as The technique has four characteristics that distinguish it from
psychomotor skills (Cowan et al., 2007). One critique of this other group decision-making processes: expert input, inter-
tradition states that this understanding of competence is too action with feedback, statistical group responses and confi-
abstract and that it ignores the qualities necessary for dentiality (Waltz et al., 2005). Our study sought to reach
application in actual situations and contexts. The third consensus amongst an expert panel. Consensus is an impor-
understanding of competence, known as ‘holistic understand- tant feature of content validity because it signifies the
ing’, includes professional and intelligent judgements and acceptability and recognisability of the NOP-CET’s content
recognises the need for reflexive practice and the importance to relevant personnel (Jirwe et al., 2009). An expert panel

© 2014 John Wiley & Sons Ltd 61


P.C. Bing-Jonsson et al.

participated in three consecutive investigations (Rounds 1, 2 by other experts. To assure the validity of the results, the
and 3). After round 1 and 2, the results were reported back to heterogeneity of participants was deemed important. To gain
the panel, who then reconsidered and responded to this new insight and opinion from various levels and standpoints
information (Keeney et al., 2011). The Delphi method was regarding nurses who care for older people, we sought
considered complete when a consensus was reached amongst participants from different professions across location, age
the experts (Fink et al., 1984; Keeney et al., 2011). and gender. The characteristics of the sample are shown in
Table 1.
Research approval was obtained from the Norwegian
Participants and sampling
Social Science Data Services, and the study was conducted in
By definition, a Delphi sample consists of experts who can be accordance with the ethical requirements of the Declaration
seen as ‘crystallisation points’ with practical insider knowl- of Helsinki (www.wma.net). Participants were initially con-
edge and as surrogates for a wider circle of stakeholders tacted via e-mail with an invitation that explained the
(Bogner et al., 2009). One difference between experts and purpose and requirements of study participation. All partic-
novices is that the former will bring more and better- ipants consented to participate in an e-mail to the first author.
organised knowledge to bear on a problem (Jensen et al., Participants were assured that their identities and the
2008). Hence, interviewing experts created an opportunity to information they provided would remain confidential. Par-
expand our access to the field. The interviewer (i.e. the first ticipation was voluntary throughout the study.
author) and the experts also shared a background and
interests, which might have served as motivation for partic-
Data collection and analysis
ipation (Bogner et al., 2009). We defined experts as
‘informed individuals’, ‘specialists in their field’ and ‘people This study consisted of three investigations, referred to as
who are knowledgeable with regard to caring for older Rounds 1, 2 and 3.
people’ (Keeney et al., 2011). Our panel consisted of 42
experts, of whom 14 were clinicians who cared for older Round 1
people, 11 were leaders or administrative personnel in Round 1 was conducted in September 2012 and consisted of
community care services, seven were nursing teachers spe- 42 individual, semistructured telephone interviews, each
cialising in care for older people, six were nursing researchers lasting approximately 30 minutes. Interviews were consid-
and four were employed in relevant patient organisations. ered appropriate for collecting a large and varied amount of
The experts were sampled individually using the snowball material for analysis. The interview guide, based on our
technique (Patton, 2002). All participants were recommended conceptualisation of competence, was e-mailed to respon-

Table 1 Expert panel characteristics

From clinical practice n = 14


Nursing staff leaders From patient
Registered Assistant and administrators Nurse lecturers Nursing researchers organisations
Nurses n = 8 nurses n = 6 n = 11 n=7 n=6 n=4

Years of experience in older people nursing


Range 6–25 24–32 6–38 15–29 12–40 16–38
Mean 16.25 27.80 20.54 20.42 23.50 28.00
Age
Range 23–51 38–59 51–65 52–65 36–79
Mean 43.57 50.64 56.71 55.17 62.00
Gender
Women 12 9 7 4 4
Men 2 2 2
Geographical Region of Norway
South 3 1
East 6 6 4 3 4
West 2 2 1
Middle 3 2 1
North 2 2

62 © 2014 John Wiley & Sons Ltd


P.C. Bing-Jonsson et al.

participated in three consecutive investigations (Rounds 1, 2 by other experts. To assure the validity of the results, the
and 3). After round 1 and 2, the results were reported back to heterogeneity of participants was deemed important. To gain
the panel, who then reconsidered and responded to this new insight and opinion from various levels and standpoints
information (Keeney et al., 2011). The Delphi method was regarding nurses who care for older people, we sought
considered complete when a consensus was reached amongst participants from different professions across location, age
the experts (Fink et al., 1984; Keeney et al., 2011). and gender. The characteristics of the sample are shown in
Table 1.
Research approval was obtained from the Norwegian
Participants and sampling
Social Science Data Services, and the study was conducted in
By definition, a Delphi sample consists of experts who can be accordance with the ethical requirements of the Declaration
seen as ‘crystallisation points’ with practical insider knowl- of Helsinki (www.wma.net). Participants were initially con-
edge and as surrogates for a wider circle of stakeholders tacted via e-mail with an invitation that explained the
(Bogner et al., 2009). One difference between experts and purpose and requirements of study participation. All partic-
novices is that the former will bring more and better- ipants consented to participate in an e-mail to the first author.
organised knowledge to bear on a problem (Jensen et al., Participants were assured that their identities and the
2008). Hence, interviewing experts created an opportunity to information they provided would remain confidential. Par-
expand our access to the field. The interviewer (i.e. the first ticipation was voluntary throughout the study.
author) and the experts also shared a background and
interests, which might have served as motivation for partic-
Data collection and analysis
ipation (Bogner et al., 2009). We defined experts as
‘informed individuals’, ‘specialists in their field’ and ‘people This study consisted of three investigations, referred to as
who are knowledgeable with regard to caring for older Rounds 1, 2 and 3.
people’ (Keeney et al., 2011). Our panel consisted of 42
experts, of whom 14 were clinicians who cared for older Round 1
people, 11 were leaders or administrative personnel in Round 1 was conducted in September 2012 and consisted of
community care services, seven were nursing teachers spe- 42 individual, semistructured telephone interviews, each
cialising in care for older people, six were nursing researchers lasting approximately 30 minutes. Interviews were consid-
and four were employed in relevant patient organisations. ered appropriate for collecting a large and varied amount of
The experts were sampled individually using the snowball material for analysis. The interview guide, based on our
technique (Patton, 2002). All participants were recommended conceptualisation of competence, was e-mailed to respon-

Table 1 Expert panel characteristics

From clinical practice n = 14


Nursing staff leaders From patient
Registered Assistant and administrators Nurse lecturers Nursing researchers organisations
Nurses n = 8 nurses n = 6 n = 11 n=7 n=6 n=4

Years of experience in older people nursing


Range 6–25 24–32 6–38 15–29 12–40 16–38
Mean 16.25 27.80 20.54 20.42 23.50 28.00
Age
Range 23–51 38–59 51–65 52–65 36–79
Mean 43.57 50.64 56.71 55.17 62.00
Gender
Women 12 9 7 4 4
Men 2 2 2
Geographical Region of Norway
South 3 1
East 6 6 4 3 4
West 2 2 1
Middle 3 2 1
North 2 2

62 © 2014 John Wiley & Sons Ltd


Competence measurement

dents ahead of the interviews. The participants discussed the

Established

Knowledge
Knowledge
Knowledge

attribute
Personal
knowledge, skills and personal attributes that are most

themes

Skills

Skills

Skills
currently needed among nurses who care for older people,
regardless of their own profession or training. The interpre-
tive process began with the first interview and continued

Assessment and taking

Assessment and taking


throughout the following interviews. The interviews were

Responsibility and
tape-recorded, and the lead researcher took notes throughout

Assessment and
taking action
the interviews. The researchers listened to all interview tapes

activeness
Treatment
Treatment
Treatment
Category
to confirm the researcher’s notes and impressions. Interviews

action

action
that elicited new themes (i.e. a respondent who said some-
thing upon which others had not already elaborated) were
considered key interviews and transcribed verbatim. We did

Common conditions that affect older people


not rely solely on transcriptions; rather, we also relied on tape

Loss of function; both acute and chronic

Early recognition of changes in patient

Observation of effects, side effects and


recordings and notes because transcripts translated from oral

Early intervention and quick action


Meaning coding (reduced to items)
to written discourses risk decontextualisation (Kvale &
Brinkmann, 2009). The notes and transcriptions were anal-

Being proactive and dynamic


ysed using meaning coding and categorisation methods

medication interactions
(Kvale & Brinkmann, 2009). In the first stage of our analysis,
we used meaning coding to concentrate the meaning of the
text into short sentences (items). Secondly, we found com-

Polypharmacy

health status
monalities among the items to establish categories (e.g.
‘Treatment’). Finally, we collapsed across many items to
establish central themes: knowledge, skills and personal
attributes. This analysis was reiterated several times to
confirm that all categories and items within the notes and

happening, how health status changes and


about the interactions of age, disease, and
transcriptions were captured. Table 2 provides an example of

medication Early recognition of what is


particular for older people. Knowledge
the analytical process.
development and functional decline
Knowledge about diseases, disease

Round 2
Table 2 Example of the analytical process; meaning coding and categorisation

how to intervene promptly


Round 2 was conducted from December 2012 to January
2013. In this round, the expert panel responded to an electronic
Meaning condensation

questionnaire via e-mail. The questionnaire consisted of the


items developed from the qualitative analysis in Round 1. The
respondents scored the items in terms of their relevance to
nurses who care for older people on a five-point Likert-type
scale, where 1 = of very little relevance, 2 = of little relevance,
3 = relevant, 4 = very relevant and 5 = decisive. Respondents
were encouraged to add additional comments in the question-
and how diseases appear differently in older

early intervention. [These situations are] not

younger people, and there are several things


people; and [we need] to understand what is

that influence these situations, such as aging,


changes in health status and with regard to
‘We need knowledge about the diseases that
older people have, like how they gradually

naire when they desired. The information from this question-


or more acutely lose their functional level

happening in certain situations, especially

as evident in older people compared with

naire resulted in one data file that was quantitatively analysed


using IBM SPSS Statistics Version 20 (Armonk, NY, USA). The
comments were sorted by theme.
Scores of 4 (very relevant) and 5 (decisive) were used to
diseases and medication’

indicate the panel’s agreement with a particular item; thus,


Excerpt interview no. 5

these scores were combined. A key question of the Delphi


method is ‘What percentage of respondents answering four or
five on an item should be considered as the cut-off for
consensus?’. The literature provides few clear guidelines with
regard to defining consensus (Keeney et al., 2011); however,
several authors have suggested using 75% as a cut-off

© 2014 John Wiley & Sons Ltd 63


Table 4 Results from Round 1: community care nursing staff competence with regard to older people nursing

Theme Category Item

Knowledge required Health promotion and General knowledge of aging Facilitate environment and activity based on
disease prevention Normal age-related changes; deficiencies in sight and hearing functional level
The personal development of older people How to involve a patient’s resources and support
The life story of individual patients ability to cope
The vulnerability that many older people experience due to the Patient and relative involvement and empowerment
loss of family, friends and function Local/national traditions, culture and identity

© 2014 John Wiley & Sons Ltd


Facilitating housing based on the functional level of older people (e.g. food, clothes, songs and activities)
The situation of next-of-kin their and their health risks What is meaningful to the individual
How to include and focus on next-of-kin/relatives (e.g. preferences in music and activities)
Person-centred care How to prevent loneliness
How to prevent falls and wounds
Treatment Common conditions affecting older people; geriatrics and mental health Psychosocial dimensions related to the mental health
Loss of function; both acute and chronic of older people
Common diagnoses (e.g. infections, diabetes, heart diseases, COPD, How to connect a symptom to a disease
cancer, Parkinson’s disease, multiple sclerosis and rheumatoid arthritis) Pharmacology and medication calculations
Pathology, prevalence and the treatment of dementia, depression and delirium Polypharmacy
Palliative care Treatment of pain Assure patient wishes and customs surrounding death
Treatment of palliative symptoms Use of the Liverpool Care Pathway (LCP) and
End-of-life care Edmonton Symptom Assessment System (ESAS)
tools
Systemic knowledge Health system organisation Routines at own workplace (e.g. those regarding
Health politics and governance patient referrals)
Resources in own municipality/organisation (e.g. assistive tools) What and to whom to report
How to make use of voluntary work New assistive care technologies; how these can
secure and improve the lives of patients
Ethics and regulations Ethical principals Trust-promoting initiatives to reduce the use of force
Ethical decision-making processes Patient rights
Relevant laws concerning community care Patient safety
Skills required Assessment and Early recognition of changes in the patient health status Early intervention and quick action
taking action Use of routines/checklists regarding objectives and systematic observations Support professional arguments with sufficient
Basic observations of pulse, blood pressure, respiration, skin, temperature, clinical evidence
consciousness and functional decline Understand the totality of a patient’s situation
Observe effects, side effects and medication interactions Resuscitation
Awareness of the complexity of polypharmacy How to contact nurses or physicians in emergencies
Analyse, interpret and assess/understand patient needs
Cover basic needs Cover basic needs based on a patient’s primary functions Ergonomic positioning of sitting and lying patients
Hand hygiene Mobilise and activate patients
Satisfactory assistance with patient oral hygiene Body mechanics and use of assistive tools
Perform procedures Simple procedures (e.g. monitoring blood glucose, injecting insulin, More advanced procedures (e.g. handling of
inserting intermittent female urinary catheters, applying transdermal intravenous pumps, intramuscular injections, EKG,

65
Competence measurement
Table 4. Continued

66
Theme Category Item

analgesic patches, dispensing medication, wound and ostomy care, tube various drains, permanent urinary catheters, VAP,
feeding, and administering nebulizer treatment) CVC and blood sampling)
Postmortem care Terminal care
Communication and Oral and written understanding of Norwegian Evidence-based competence: up-to-date information
P.C. Bing-Jonsson et al.

documentation Communication with older people, especially those with for practice
dementia: talk slowly, say one thing at a time in a calm voice, wait Make use of tools for project management
for a response, initiate physical contact, reduce stimuli, listen, let the Make use of electronic tools for nursing procedures
patient be active Register patient in a national community care
Have the ‘difficult talk’ regarding death register
Keep confidentiality Electronically document: write assessments of
Develop a nursing plan patients, document in a sufficiently understandable
Coordinate individual plans for patients language; provide correct patient reports; follow
the national guidelines concerning patient
documentation
Communicate with multicultural patients
Personal attributes Responsibility and Recognise one’s own responsibility and contribution to Prioritise
required activeness the healthcare system Be proactive and dynamic
Take responsibility Do not necessarily accept that a patient is
Advocate for the patient undemanding and content
Provide clear instructions or authorisation when necessary Be innovative, creative and find solutions
Set clear limits; do not do everything for the patient
Cooperation Cooperate across professions Systematically teach and guide patients and
Participate in team work next-of-kin/relatives
Cooperate with next-of-kin Work independently
Provide and receive guidance from colleagues
Self-awareness and Insight regarding how one affects other people Be aware of own limitations regarding competence
personal development Constantly self-develop; be open to change Having high self-esteem
Be adjustable Feel assured with regard to one’s own competence
Tolerate stress and tackle one’s own responsibilities
Attitudes towards Interpersonal skills Show humility
older people Being fond of/appreciate older people Be inclusive
Show respect/moral behaviour Meet a patient at his or her level
Care Treat all patients equally
Empathise
Professional behaviour Aesthetics, including wearing modest clothing Show respect when entering someone’s home
Have good manners (e.g., greet politely and ring doorbell) Keep appointments and be predictable
110 items in total

© 2014 John Wiley & Sons Ltd


Table 4 Results from Round 1: community care nursing staff competence with regard to older people nursing

Theme Category Item

Knowledge required Health promotion and General knowledge of aging Facilitate environment and activity based on
disease prevention Normal age-related changes; deficiencies in sight and hearing functional level
The personal development of older people How to involve a patient’s resources and support
The life story of individual patients ability to cope
The vulnerability that many older people experience due to the Patient and relative involvement and empowerment
loss of family, friends and function Local/national traditions, culture and identity

© 2014 John Wiley & Sons Ltd


Facilitating housing based on the functional level of older people (e.g. food, clothes, songs and activities)
The situation of next-of-kin their and their health risks What is meaningful to the individual
How to include and focus on next-of-kin/relatives (e.g. preferences in music and activities)
Person-centred care How to prevent loneliness
How to prevent falls and wounds
Treatment Common conditions affecting older people; geriatrics and mental health Psychosocial dimensions related to the mental health
Loss of function; both acute and chronic of older people
Common diagnoses (e.g. infections, diabetes, heart diseases, COPD, How to connect a symptom to a disease
cancer, Parkinson’s disease, multiple sclerosis and rheumatoid arthritis) Pharmacology and medication calculations
Pathology, prevalence and the treatment of dementia, depression and delirium Polypharmacy
Palliative care Treatment of pain Assure patient wishes and customs surrounding death
Treatment of palliative symptoms Use of the Liverpool Care Pathway (LCP) and
End-of-life care Edmonton Symptom Assessment System (ESAS)
tools
Systemic knowledge Health system organisation Routines at own workplace (e.g. those regarding
Health politics and governance patient referrals)
Resources in own municipality/organisation (e.g. assistive tools) What and to whom to report
How to make use of voluntary work New assistive care technologies; how these can
secure and improve the lives of patients
Ethics and regulations Ethical principals Trust-promoting initiatives to reduce the use of force
Ethical decision-making processes Patient rights
Relevant laws concerning community care Patient safety
Skills required Assessment and Early recognition of changes in the patient health status Early intervention and quick action
taking action Use of routines/checklists regarding objectives and systematic observations Support professional arguments with sufficient
Basic observations of pulse, blood pressure, respiration, skin, temperature, clinical evidence
consciousness and functional decline Understand the totality of a patient’s situation
Observe effects, side effects and medication interactions Resuscitation
Awareness of the complexity of polypharmacy How to contact nurses or physicians in emergencies
Analyse, interpret and assess/understand patient needs
Cover basic needs Cover basic needs based on a patient’s primary functions Ergonomic positioning of sitting and lying patients
Hand hygiene Mobilise and activate patients
Satisfactory assistance with patient oral hygiene Body mechanics and use of assistive tools
Perform procedures Simple procedures (e.g. monitoring blood glucose, injecting insulin, More advanced procedures (e.g. handling of
inserting intermittent female urinary catheters, applying transdermal intravenous pumps, intramuscular injections, EKG,

65
Competence measurement
Table 4. Continued

66
Theme Category Item

analgesic patches, dispensing medication, wound and ostomy care, tube various drains, permanent urinary catheters, VAP,
feeding, and administering nebulizer treatment) CVC and blood sampling)
Postmortem care Terminal care
Communication and Oral and written understanding of Norwegian Evidence-based competence: up-to-date information
P.C. Bing-Jonsson et al.

documentation Communication with older people, especially those with for practice
dementia: talk slowly, say one thing at a time in a calm voice, wait Make use of tools for project management
for a response, initiate physical contact, reduce stimuli, listen, let the Make use of electronic tools for nursing procedures
patient be active Register patient in a national community care
Have the ‘difficult talk’ regarding death register
Keep confidentiality Electronically document: write assessments of
Develop a nursing plan patients, document in a sufficiently understandable
Coordinate individual plans for patients language; provide correct patient reports; follow
the national guidelines concerning patient
documentation
Communicate with multicultural patients
Personal attributes Responsibility and Recognise one’s own responsibility and contribution to Prioritise
required activeness the healthcare system Be proactive and dynamic
Take responsibility Do not necessarily accept that a patient is
Advocate for the patient undemanding and content
Provide clear instructions or authorisation when necessary Be innovative, creative and find solutions
Set clear limits; do not do everything for the patient
Cooperation Cooperate across professions Systematically teach and guide patients and
Participate in team work next-of-kin/relatives
Cooperate with next-of-kin Work independently
Provide and receive guidance from colleagues
Self-awareness and Insight regarding how one affects other people Be aware of own limitations regarding competence
personal development Constantly self-develop; be open to change Having high self-esteem
Be adjustable Feel assured with regard to one’s own competence
Tolerate stress and tackle one’s own responsibilities
Attitudes towards Interpersonal skills Show humility
older people Being fond of/appreciate older people Be inclusive
Show respect/moral behaviour Meet a patient at his or her level
Care Treat all patients equally
Empathise
Professional behaviour Aesthetics, including wearing modest clothing Show respect when entering someone’s home
Have good manners (e.g., greet politely and ring doorbell) Keep appointments and be predictable
110 items in total

© 2014 John Wiley & Sons Ltd


Competence measurement

international trends that emphasise the principals of com-


munity health care and the alteration of healthcare services
References
(Romøren et al., 2011), our findings are likely to be gener- Aldridge-Bent S. (2011) Advanced physical assessment skills: imple-
alisable to other developed nations. Assuming that older mentation of a module. British Journal of Community Nursing 16,
people in need of health care have the same needs across 84–88.
Angermann A. & Eichhorst W. (2012) Eldercare Services – Lessons
borders, our findings might be used as a basis or comparison
from a European Comparison IZA Research Report. Deutscher
for other international studies examining competence among
Verein f€ € ffentliche und private F€
ur o ursorge e.V., Berlin, pp. 1–38.
nurses who care for older people. Because this study applied a Baker R., Wensing M. & Gibis B. (2006) Improving the quality and
contextual understanding of competence, the environment in performance of primary care. In Primary Care in the Driver’s Seat?
which nurses who care for older people work should always Organizational Reform in European Primary Care (Saltman R.B.,
be considered. Rico A. & Boerma W.G.W. eds). Open University Press, Berkshire,
pp. 203–226.
Benner P. (1984) From Novice to Expert: Excellence and Power in
Conclusions Clinical Nursing Practice. Addison-Wesley, Menlo Park, CA.
Benner P., Sutphen M., Leonard V. & Day L. (2010) Educating
This Delphi method revealed a clear consensus with regard to Nurses: A Call for Radical Transformation. Jossey-Bass, San
the competence required among nurses who care for older Francisco, CA.
Bing-Jonsson P.C., Bjørk I.T., Hofoss D., Kirkevold M. & Foss C.
people in Norwegian community care environments. Experts
(2013) Instruments measuring nursing staff competence in com-
agreed that health promotion and disease prevention, treat-
munity health care. A systematic literature review. Home Health
ment, palliative care, ethics and regulation, assessment and Care Management & Practice 25, 282–294.
taking action, covering basic needs, communication and Boerma W.G.W. (2006) Coordination and integration in European
documentation, responsibility and activeness, cooperation, primary care. In Primary Care in the Driver’s Seat? Organizational
and attitudes towards older people were the most relevant Reform in European Primary Care (Saltman R.B., Rico A. &
Boerma W.G.W. eds). Open University Press, Berkshire, pp. 3–21.
categories of competence. This article argued why its results
Bogner A., Littig B. & Menz W. (2009) Introduction: expert
provide evidence for the content validity of the NOP-CET. interviews – an introduction to a new methodological debate. In
Because older people nursing is rapidly evolving and the Interviewing Experts (Bogner A., Littig B. & Menz W. eds).
demands on nursing staff are increasing and changing, it is Palgrave Macmillian, Basingstoke, pp. 1–16.
necessary to follow these developments with scientific Colombo F., Llena-Nozal A., Mercier J. & Tjadens F. (2011) Help
Wanted? OECD Publishing, Paris.
enquiry. We propose a valid and comprehensive evaluation
Commisson E. (2012) The 2012 Ageing Report. Economic and
tool to evaluate the competence of modern nursing staff and
Budgetary Projections for the 27 EU Member States (2010–2060).
to determine what competence must be developed in the European Commission, Brussels.
future. Cowan D.T., Norman I. & Coopamah V.P. (2007) Competence in
nursing practice: a controversial concept – A focused review of
literature. Accident and Emergency Nursing 15, 20–26.
Donabedian A. & Bashshur R. (2003) An Introduction to Quality
Implications for practice Assurance in Health Care. Oxford University Press, Oxford.
Eraut M. (1994) Developing Professional Knowledge and Compe-
 A wide spectre of competence is required of nursing
tence. Falmer Press, London.
staff to meet the needs of older patients in community Field A. (2013) Discovering Statistics using IBM SPSS Statistics, Vol.
health care. 4. SAGE, Los Angeles.
 Competence must be developed to reach the required Fink A., Kosecoff J., Chassin M. & Brook R.H. (1984) Consensus
levels of competence. methods: characteristics and guidelines for use. American Journal
 Competence assessments can be helpful in the exam- of Public Health 74, 979–983.
Fur aker C. (2012) Registered nurses’ views on competencies in home
ination of competence with regard to competence
care. Home Health Care Management & Practice 24, 221–227.
development. Garside J.R. & Nhemachena J.Z.Z. (2013) A concept analysis of
competence and its transition in nursing. Nurse Education Today
33, 541–545.
Gautun H. & Hermansen  A. (2011) Geriatric Care under Pressure.
Contributions Municipal Health and Care Services for the Elderly. Forskningss-
tiftelsen FAFO, Oslo [in Norwegian].
Study design: PCBJ, ITB, DH, MK, CF; data collection and Greatorex J. & Dexter T. (2000) An accessible analytical approach
analysis: PCBJ, ITB, DH, MK, CF and; manuscript prepara- for investigating what happens between the rounds of a Delphi
study. Journal of Advanced Nursing 32, 1016–1024.
tion: PCBJ, ITB, DH, MK, CF.

© 2014 John Wiley & Sons Ltd 71


P.C. Bing-Jonsson et al.

people nursing. This conclusion also supports the content Furthermore, consensus might not have been reached for
validity of the NOP-CET. Although non-parametric analyses the items concerning advanced nursing competence (and
are conservative in that they are less powerful than parametric other items that could have been incorrectly omitted) due to
tests, non-parametric tests should be applied to small data sets our choice of cut-off. If we had set the cut-off level to 75%,
that are not normally distributed (Field, 2013). more items would have been included (e.g. those concerning
Several analysts have emphasised how competence-based advanced procedures and evidence-based competence). All
approaches to nursing education and practice are likely to 110 items from Round 1 were initially judged as important
emphasise technical and instrumental competence because by at least one expert; one might wonder why all the items
these concepts are easier to measure than those that are were not included. Note that the Delphi method aims to
intangible (Watson et al., 2002; Cowan et al., 2007). Before reach a consensus concerning what is most relevant. A key
commencing this study, we were concerned that the experts question in any Delphi study is what percentage to accept as
would emphasise technical and instrumental competence (i.e. synonymous with consensus (Keeney et al., 2006). Although
performance) and place less emphasis on knowledge and the literature does not provide clear guidelines with regard
personal attributes. Messick (1995) argues that a compe- to setting consensus level, establishing a cut-off is crucial for
tence–performance gap exists, which has implications for determining which items are discarded or retained through-
assessment methodologies (i.e. one is more likely to measure out the rounds. However, determining which cut-off level to
performance than competence). However, our concern was set might lie within the research topic. Because older people
alleviated because consensus was reached with regard to nursing is a vast field that includes competence spanning
items within each theme (i.e. knowledge, skills and personal from psychiatry to end-of-life treatment, it is useful to
attributes). A large portion of the items to which consensus determine what distinguishes it from other fields of care. A
was reached encompassed so-called intangible competence lenient cut-off would allow for more items to be included,
(e.g. items in the categories responsibility and activeness, but this choice might leave the final sample of items less
cooperation, and attitudes towards older people). Through- distinct from other nursing fields. A strict cut-off of 90%
out the Round 1 interviews, the experts were focused on this requires that a strong consensus be reached for every
type of competence and how this is required of all community included item and ensures that each item is related and
care staff, regardless of their qualifications. relevant to older people nursing. The high cut-off for
consensus in this study supports the content validity for the
included items. Furthermore, our high response rates
New competence demands
(100%, 100% and 93%) indicate the commitment and
We initially described the status of older people nursing in engagement of our panel. Their heterogeneity allowed for a
developed countries as critical and stated that high compe- range of views to be elicited; moreover, participants’
tence demands are placed on nursing staff. The complexity of expertise in the field and their commitment to this study
dealing with frail older people with multiple diseases and are additional signs of content validity.
cognitive failure who are taking a spectrum of different
medicines demands advanced nursing competence in geriat-
Limitations
rics, psychiatry, communication, advanced practical skills
and evidence-based practice (Scott, 2008; Schoen et al., Items concerning specific, advanced competence did not
2011; Fur aker, 2012). However, our study revealed that reach consensus although international trends highlight their
experts in caring for older people did not reach consensus importance. Therefore, additional investigations of the
with regard to several items concerning advanced nursing. importance of advanced competence among nurses who care
Measuring all caregivers as one staff might explain the for older people seem appropriate. Although the Delphi
exclusion of items concerning advanced nursing competence. method is appropriate for determining necessary competence,
In Rounds 2 and 3, the experts rated competence relevance, this technique is limited in that new demands do not
regardless of a caregiver’s education and training. Several necessarily reach consensus as they take time to be incorpo-
experts expressed that they found this task difficult because rated within practices and thus also within the experts
they connected length of education and training with descriptions. This limitation of Delphi studies is known
different competence. Thus, certain items concerning (Keeney et al., 2011) and confirmed in this study. Another
advanced techniques might have been excluded because this limitation is that this study was performed in one country and
kind of competence does not pertain to the staff who was therefore influenced by the structures of a particular
currently work in this field according to the experts. healthcare system. However, given that Norway follows

70 © 2014 John Wiley & Sons Ltd


Competence measurement

international trends that emphasise the principals of com-


munity health care and the alteration of healthcare services
References
(Romøren et al., 2011), our findings are likely to be gener- Aldridge-Bent S. (2011) Advanced physical assessment skills: imple-
alisable to other developed nations. Assuming that older mentation of a module. British Journal of Community Nursing 16,
people in need of health care have the same needs across 84–88.
Angermann A. & Eichhorst W. (2012) Eldercare Services – Lessons
borders, our findings might be used as a basis or comparison
from a European Comparison IZA Research Report. Deutscher
for other international studies examining competence among
Verein f€ € ffentliche und private F€
ur o ursorge e.V., Berlin, pp. 1–38.
nurses who care for older people. Because this study applied a Baker R., Wensing M. & Gibis B. (2006) Improving the quality and
contextual understanding of competence, the environment in performance of primary care. In Primary Care in the Driver’s Seat?
which nurses who care for older people work should always Organizational Reform in European Primary Care (Saltman R.B.,
be considered. Rico A. & Boerma W.G.W. eds). Open University Press, Berkshire,
pp. 203–226.
Benner P. (1984) From Novice to Expert: Excellence and Power in
Conclusions Clinical Nursing Practice. Addison-Wesley, Menlo Park, CA.
Benner P., Sutphen M., Leonard V. & Day L. (2010) Educating
This Delphi method revealed a clear consensus with regard to Nurses: A Call for Radical Transformation. Jossey-Bass, San
the competence required among nurses who care for older Francisco, CA.
Bing-Jonsson P.C., Bjørk I.T., Hofoss D., Kirkevold M. & Foss C.
people in Norwegian community care environments. Experts
(2013) Instruments measuring nursing staff competence in com-
agreed that health promotion and disease prevention, treat-
munity health care. A systematic literature review. Home Health
ment, palliative care, ethics and regulation, assessment and Care Management & Practice 25, 282–294.
taking action, covering basic needs, communication and Boerma W.G.W. (2006) Coordination and integration in European
documentation, responsibility and activeness, cooperation, primary care. In Primary Care in the Driver’s Seat? Organizational
and attitudes towards older people were the most relevant Reform in European Primary Care (Saltman R.B., Rico A. &
Boerma W.G.W. eds). Open University Press, Berkshire, pp. 3–21.
categories of competence. This article argued why its results
Bogner A., Littig B. & Menz W. (2009) Introduction: expert
provide evidence for the content validity of the NOP-CET. interviews – an introduction to a new methodological debate. In
Because older people nursing is rapidly evolving and the Interviewing Experts (Bogner A., Littig B. & Menz W. eds).
demands on nursing staff are increasing and changing, it is Palgrave Macmillian, Basingstoke, pp. 1–16.
necessary to follow these developments with scientific Colombo F., Llena-Nozal A., Mercier J. & Tjadens F. (2011) Help
Wanted? OECD Publishing, Paris.
enquiry. We propose a valid and comprehensive evaluation
Commisson E. (2012) The 2012 Ageing Report. Economic and
tool to evaluate the competence of modern nursing staff and
Budgetary Projections for the 27 EU Member States (2010–2060).
to determine what competence must be developed in the European Commission, Brussels.
future. Cowan D.T., Norman I. & Coopamah V.P. (2007) Competence in
nursing practice: a controversial concept – A focused review of
literature. Accident and Emergency Nursing 15, 20–26.
Donabedian A. & Bashshur R. (2003) An Introduction to Quality
Implications for practice Assurance in Health Care. Oxford University Press, Oxford.
Eraut M. (1994) Developing Professional Knowledge and Compe-
 A wide spectre of competence is required of nursing
tence. Falmer Press, London.
staff to meet the needs of older patients in community Field A. (2013) Discovering Statistics using IBM SPSS Statistics, Vol.
health care. 4. SAGE, Los Angeles.
 Competence must be developed to reach the required Fink A., Kosecoff J., Chassin M. & Brook R.H. (1984) Consensus
levels of competence. methods: characteristics and guidelines for use. American Journal
 Competence assessments can be helpful in the exam- of Public Health 74, 979–983.
Fur aker C. (2012) Registered nurses’ views on competencies in home
ination of competence with regard to competence
care. Home Health Care Management & Practice 24, 221–227.
development. Garside J.R. & Nhemachena J.Z.Z. (2013) A concept analysis of
competence and its transition in nursing. Nurse Education Today
33, 541–545.
Gautun H. & Hermansen  A. (2011) Geriatric Care under Pressure.
Contributions Municipal Health and Care Services for the Elderly. Forskningss-
tiftelsen FAFO, Oslo [in Norwegian].
Study design: PCBJ, ITB, DH, MK, CF; data collection and Greatorex J. & Dexter T. (2000) An accessible analytical approach
analysis: PCBJ, ITB, DH, MK, CF and; manuscript prepara- for investigating what happens between the rounds of a Delphi
study. Journal of Advanced Nursing 32, 1016–1024.
tion: PCBJ, ITB, DH, MK, CF.

© 2014 John Wiley & Sons Ltd 71


P.C. Bing-Jonsson et al.

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