Bing Jonsson2014
Bing Jonsson2014
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.
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.
•
(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,
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
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-
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-
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
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
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
Round 2
Table 2 Example of the analytical process; meaning coding and categorisation
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
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
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
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
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
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