The Components of Nursing Competence in Caring for Older People in Iranian Hospitals: A Qualitative Study.

BACKGROUND: There is limited research on gerontological nursing competence in hospitals. However, there is no comprehensive and integrated description of the gerontological nursing competence requirements in hospitals. The purpose of this study was to explain the components of nursing competence in caring for older people in Iranian hospitals.
MATERIALS AND METHODS: This is a qualitative descriptive-exploratory study. The data were collected through a semi-structured interview with nurses, nurse managers, and clinical educators in teaching hospitals and nursing schools affiliated to Arak, Isfahan, and Tehran Universities of Medical Sciences in Iran from September 2015 to July 2016. Participants included 25 people who were selected by purposive and snowball sampling method. Sampling continued until data saturation. Data were analyzed using conventional content analysis method.
RESULTS: Data analysis generated three main categories including (1) Patient and family centered care; (2) Process-oriented care; and (3) Self-care and continuing professional development.
CONCLUSIONS: Nurses should have competencies such as participation and empowerment of the patient and family; ease of comfort in the elderly; comprehensive geriatric assessment; development, implementation and evaluation of care plan; development of knowledge and clinical proficiency; and coaching so that they can work effectively during the care of the elderly. The results of this study can be used by nursing educators, nursing students, and nurses to develop their individual and professional skills in the field of gerontological nursing.

Introduction

One of the main challenges of the health care system is the increasing number of elderly patients visiting hospitals with unique and complex needs.[1] Because of the aging process, the weakening of both physical and mental functions leads to a weaker performance and higher rates of disability and death in the elderly.[2] Elderly people are prone to complications and problems such as delirium, motor disability, sepsis, pressure ulcers, poor nutrition, fall, incontinence, and thrombolytic diseases.[13] Other health-related challenges in the elderly include several chronic illnesses at the same time, atypical manifestations of acute illnesses, the need for additional support for everyday activities, polypharmacy issues, and frequent use of health care services.[4]

Proper nursing interventions are necessary to ensure the quality of care and safety of this group of patients. Among inappropriate nursing interventions are frequent use of restraints to prevent falls, or the insertion of a urinary catheter to avoid intrusions, pain, and pressure of needing to go to the toilet, which can affect patients' dignity and create potential dangers for the hospitalized elderly.[5] In some cases, nurses categorize the symptoms of acute illnesses as part of an aging process. Acute confusion (delirium and an internal emergency) is repeatedly interpreted as a normal aspect of aging, which does not require any special intervention.[6]

Gerontological nursing is a professional care that needs special attention. It is essential to identify the components of gerontological nursing competence. Identification of gerontological nursing competencies elements for human resources development and management is essential.[7] The American Association of College of Nursing (AACN), in collaboration with the Hartford Institute, has proposed competencies and guidelines for gerontological nursing curricula.[8] Studies have also been conducted to identify the competencies of gerontological nursing in different settings.[9101112] However, there is limited research on gerontological nursing competence in hospitals.[13] Therefore, there is no comprehensive and integrated description of gerontological nursing competence requirements in hospitals.

Despite the importance of human resources management, training, and assessment of competence-based performance, there are no national standards for nursing competencies regarding care for the elderly in Iran. So far, no study has been conducted to identify the qualifications of gerontological nursing comptence. Therefore, there is no clear definition in this regard. To identify the components of gerontological nursing competence, qualitative research is essential. The purpose of this study was to explain the components of nursing competence in caring for older people in Iranian hospitals.

Materials and Methods

A qualitative descriptive-exploratory study was conducted to achieve a deep understanding and explain nursing competence components in caring for older people from 2015 to 2016. The main purpose of descriptive-exploratory studies is to describe or explore a phenomenon, problem, or subject, and includes a wide range of questions on individuals' experiences, knowledge, attitudes, emotions, and perceptions, or views points.[14]

The study was conducted in university hospitals and nursing schools affiliated with Arak, Isfahan, and Tehran Universities of Medical Sciences in Iran. This study was part of a larger project that aims to develop a gerontological nursing competence questionnaire in Iranian hospitals. The current paper presents the results of the exploratory phase with the aim of explaining the components of nursing competence in caring for older people in Iranian hospitals.

Semi-structured interviews were conducted with 25 participants until data saturation. Purposive and snowball sampling was used to select participants [Table 1]. Primary participants were nursing managers and staff nurses who were selected as the experienced gerontological nursing caregivers on the basis of the introduction of nursing offices. Some participants were selected by snowball method and introduced by previous participants. Sampling continued until data saturation (either the obtained data were repeated or the new data confirmed the previous ones). After conducting interviews with 21 participants, the data were saturated, and four further interviews were conducted to confirm the formed categories and sub-categories, and finally, the data were completed. The inclusion criteria were willingness to participate in the study, holding at least a bachelor's degree, and having at least one year of clinical work experience in adult wards.

Table 1

Participant characteristics (n=25)

Characteristic	Value
Job status, n
Nurse	9
Head nurse	8
Clinical supervisor	2
Educational supervisor	1
Head of nursing office of the hospital	1
Clinical instructor	4
Education level, n
Bachelor’s degree	13
Master’s degree	5
MS student	3
PHD candidate	4
Gender, n
Female	21
Male	4
Work experience (year), range	1-25
Age (year), range	23-48

The interviews conducted by the researchers introducing themselves and a brief description of the study objectives. Length of interviews varied between 20 and 60 min (average of 40 min) and they were conducted in a peaceful place, chosen by the participants. The location and time of the interviews were determined according to the participants in their workplace, home, and office or the researcher's office.

The interview guide included questions, such as “What experiences did you have in caring of the elderly patient in hospitals?", and “What are the characteristics of a competent nurse in the field of gerontological nursing in hospitals?"

Data analysis was concurrent with data collection. Data were analyzed through conventional content analysis approach. All interviews were audio-recorded and transcribed verbatim. The transcribed interviews were reviewed several times. The text was divided into meaning units. Primary codes were extracted. Through comparing the codes in terms of their differences and similarities, subcategories were extracted. Finally, the subcategories were compared and combined in case of similarity, and thus, the main categories were revealed.[15] Table 2 shows the inductive process of reaching category of “patient and family centered care."

Table 2

Process of developing the “patient and family centered care” category

Category	Subcategories	Codes	Meaning units
Patient and family centered care	Participation and empowerment of the patient and family	Family’s help and participation in precise assessment of the elder’s habitsEffect of participation in improvement of nurse-elder communication	“Only the elderly’s family knows their habits and mood when they are admitted. When I get help from her daughter, she explains a lot about her habits... She says my mother is used to doing this at this hour... Getting help from their accompanying persons is very helpful. In this way, the nurse gets the information by which he or she can communicate with the elderly effectively and properly” (Nurse 2).
	Ease of comfort in the elderly	Providing of facilities and the appropriate physical environment for older people in the hospitalRelief of pain	“Our department does not have a place for a handle... The Handrail is over there... Think, for example, that the elderly is going to the toilet and all the equipment available is two pillars... Our physical environment is not desirable for the elderly” (Head Nurse 1).“Some nurses think that the elderly pretends, and consequently, pay no attention to them. For example, when the elder says my heart hurts, my hand aches, they reply, you are old…” (Nurse 1)

To establish the credibility of findings, some extracted codes were checked by a number of participants and were modified if needed (member checking was employed). Moreover, interviewing with nurses, interviewing with nurse managers, and clinical instructors were used in data collection (source triangulation). All of extracted interviews transcriptions, codes, and categories were reviewed and approved by the first and third authors of this paper (peer check). To assure the dependability and confirmability of findings, the steps and process of the research were reported and recorded precisely as much as possible (audit trial). To establish the transferability, it was attempted to reach this criterion as well through providing exact description of the population and research setting together with the characteristics of the participants and sampling with maximum variation.[16]

Ethical considerations

This research was approved by the Ethics Committee at Isfahan University of Medical Sciences (No. 394436) and Arak University of Medical Sciences (No. 1394.123). At the beginning of each interview, the participants were explained about the purpose of the research, the interview method, the confidentiality of the information, and that participating in the study was optional, and further, a written informed consent was obtained from them. Participants were also asked permission for recording the interview before the interview began.

Results

Analysis of the interview data led to identification of three categories and seven sub-categories [Table 3]. Findings related to emotional competence have been discussed in another article.[17]

Table 3

Categories and sub-categories of nursing competence in caring for older people in Iranian hospitals

Categories	Sub-categories
Patient and family centered care	1. Participation and empowerment of the patient and family2. Ease of comfort in the elderly
Process-oriented care	1. Comprehensive geriatric assessment2. Development, implementation, and evaluation of care plan
Self-care and continuing professional development	1. Self-care2. Development of knowledge and clinical proficiency3. Coaching

Category 1: Patient and family centered care

Participation and empowerment of the patient and family

This competence includes the sub-competencies of assessing family knowledge and skills to draw on their own abilities and resources for self-care and health promotion; assessing the knowledge, skills, needs, and stress levels of the family in co-operation and providing care for the elderly; helping the family to reduce stress and maintain their physical and mental health; assuring participation of older people and their families in decision making; assessing the knowledge, skills, and the needs of older people and their families in discharge planning; assessing sources of power, support, or care at home; participation and involvement of older people and their families in planning of discharge; providing information to older people and family, and their empowerment (e.g., medicational, palliative and rehabilitative care, post-discharge follow-up, and community resources in assisting older adults and their families); and being sure of elder patients' learning, evaluating the obtained education, provided to the elderly and their families, and giving them a corrective feedback.

“…I called her daughter the next hour. She came and it really affected her mood…some families really help, they clean the patients' scarf or change their clothes… and bring them their favorite food” (Nurse 1).

“…most of them are deaf, you have to repeat the education for them or get a feedback… For example, I ask mother (the patient), I told you how to take this drop? How often a day should you take it. How should you apply it?… so as to be sure that she has learned the education" (Head Nurse 3).

“If the elderly really want to learn and can do it, we teach them personally, if not, we educate their families. For example, during discharge, I have frequently said, mother (the patient) take this medicine in the morning, as it is diuretic, many times, and she says I do not understand at all, tell my daughter…then, I give a note to her daughter with the instructions" (Nurse 1).

Ease of comfort in the elderly

According to the participants' experiences, the elderly look for nurses who pay close attention to them and regularly monitor them. This makes the elderly feel more comfortable. Trusting nurses' knowledge, skills, and abilities makes comfort for the older people. Other resources for the comfort of the elderly patients are creation of facilities and a supportive environment, appropriate to the elderly in the hospital; timely consideration of the care needs, expressed by the elderly patient and perceived by the nurses; and relief of pain and the provision of basic and individual elderly's health needs with the aim of creating comfort, peace, independence, and the safety. Therefore, the nurse's ability to provide comfort among the elderly was considered.

“The tools and the things the elderly need should be available to them not to look for, for example, many have a lot of dependence on their watch or sticks” (Head Nurse 2).

“An elder patient feels cold much sooner than other patients. For example, we turn on air conditioner at night. We are young and are working. So, we don't feel cold, but they shiver with cold that time and require an extra blanket. We should make a comfortable environment for them…and diminish the noise as much as possible as they all have sleep problems” (Nurse 2).

Category 2: Process-oriented care

Comprehensive geriatric assessment

According to the participants, the competence for a comprehensive geriatric assessment includes the sub-competences of ability to take assessment; taking a comprehensive assessment of the health status and social support of the elderly; assessment of spirituality needs; assessment of aging syndromes signs; evaluation of elderly's supportive resources; assessment of risk factors for the elderly's health; comprehensive medication assessment; differentiation of normal aging from illness processes; diagnosis of typical and atypical manifestations of chronic and acute illnesses and diseases of old age; diagnosis of complications and treatment problems in the vulnerable elderly; and interpretation of laboratory results and diagnostic tests according to different values for the elderly.

“An old man who cannot move in the house, for example, may either have pressure ulcer while his family have not noticed, or be predisposed to for which the nurses should be more curious and careful… We had patients who complained of back burn, and after checking that, we found an ulcer” (Head Nurse 4).

“Be sure to have checked out the support system of the elderly to see who are available, are there supportive systems, and are they willing to help” (Clinical Instructor 2).

Development, implementation, and evaluation of care plan

According to participants' statements, nurses should have the necessary competencies in the fields of development, implementation, and evaluation of care plans with regard to management of cognitive disorders; pain management; performance enhancement; management of sleep disorders; prevention of common medication related problems; preventing falls and injuries; prevention of hospital acquired infections; preventing nutritional and fluid disorders; managing common urinary, genital, and intestinal disorders; management of misbehaving toward the elderly; and eliminating or minimizing the use of restrictive measures; and meeting the spiritual needs of the elderly.

“For example, mistaking Warfarin with Nitrocantin, when you ask “do you take the pink pill, they answer yes". But, when you check the box, you see they are mistaking Warfarin with Nitrocantin and vice versa, as they are the same colors” (Nurse 4).

“Their nutrition may be neglected… for example, he/she has no need to eat all these fruits, or need no calories… most of them get dehydrated, when they get older. They may not even have a glass of water in a day. They think they need not much water as they are old although they are wrong” (Head Nurse 5).

“When you go to the patient, for example, to control the bleeding caused by angiocatheter, I may see the accompanying person may beating him/her twice on head…I say do not do that, you should take care of him/her as they are disabled! …why do you behave with and talk to him/her like this!” (Nurse 6).

“The current spiritual counseling is really helpful and is a good option. Spiritually, the elderly have a special dedication to the clerics. When they talk to them, they calm down… I myself refer those who are afraid of death, or, for example, in case of religious affairs, to the clergy of the centre” (Head Nurse 4).

Category 3: Self-care and continuing professional development

Self-care

According to the participants, one of the factors enhancing the quality of gerontological nursing care is paying nurses' attention to their self-care and promotion of their own health in all aspects. “One of the most important issues in the gerontological nursing competence is nurses' self-care competence. You see, when nurses can take care of themselves and have better health, they can better play a role in others' health. Nurses who care their own health can definitely better manage the occupational and familial stress at work, and consequently, provide the patients with a higher quality care" (Clinical Instructor 4).

Development of knowledge and clinical proficiency

According to the participants, the competence for development of knowledge and clinical proficiency includes the sub-competences of awareness of one's personal and professional strengths and weaknesses in the field of gerontological nursing; taking advantage of opportunities to grow one's individual and professional gerontological care; commitment and eagerness to learn gerontological care; accepting criticism; and care development from professional theoretical knowledge of the elderly and skillful technical care development.

“We should be aware that Bipyridine, which is an anticholinergic drug, may cause dementia in the elderly… in no circumstances, inject haloperidol with bipyridine as extrapyramidal complications are much lower in elderly people…” (Head Nurse 7).

“We learn many things from the elderly, we learn from their family. Or, if we learn that what we have done today can be to the benefit of the patient, we reinforce it; and, if we learn that what we have done today can be harmful to the patient, we remove it” (Nurse 8).

“Being eager. Eager to increase their knowledge of geriatric nursing, like learning the communication skills” (Nurse 1).

Coaching

One of the key competencies to improve the quality of gerontological nursing care is to play the role of a coach. According to the participants, the coaching role of nurses focuses on providing education and assisting personal and professional development of other colleagues in the field of gerontological nursing, as one of the most important competencies in gerontological nursing. “I think the training we give to the service personnel is very important… for example, Sir, if you move the patient or the bed, you have to push up the restrictors to prevent patients' fall while moving" (Head Nurse 3).

Discussion

The present study is the first qualitative work in Iranian society that examines the dimensions of gerontological nursing competence in hospitalized elderly patients. The findings of this study showed that the most important gerontological nursing competencies included patient and family centered care; process-oriented care; and self-care and continuing professional development.

The category of patient and family centered care represents the nurses' competence in facilitating the participation and empowerment of the elderly and their families as well as making comfort in the elderly. The results of this study showed that focusing on the transmission of information or participation of the elderly is not enough in discharge planning. Rather, assessing the level of patients' readiness; assessing support resources; empowering and meeting the needs of the family; evaluating the training program; and providing feedback should also be considered. Storm et al. (2014) highlighted the challenges of discharge of the elderly from the hospital to the lack of information transfer, limited family involvement, lack of preparation of family and patients for discharge, lack of systematic patient assessment, and lack of qualified personnel in the care team.[18]

Family-centered care was proposed as an important competency in gerontological nursing. In this regard, Dehghan Nayeri et al. (2015) described the presence of family caregivers in the hospital as the main factor in providing mental and emotional support to the elderly in Iran.[3] Other studies also showed that family involvement and participation, especially for patients with dementia, contributed to providing care.[1920] In addition, findings of a review study by Morrow and Nicholson (2016) revealed that the main components of empowerment of caregivers in hospital care include patients' care, participation in decision making, information sharing, caregivers' support and education, caregivers' feedback, and transitional care.[21]

In the present study, provision of facilities and the appropriate physical environment to meet the unique needs of hospitalized older people was identified as another competency, required in gerontological nursing. This is despite the fact that the results of studies in Iran and other countries indicate a disparity between the physical environment and the needs of the elderly,[1922] which can affect the way nurses operate. Yousefi et al. (2009) described the relief of suffering in a calm environment as a feature for the concept of need for comfort in patients, hospitalized in Iran, which is consistent with the findings of the present study.[23]

The elderly demand the care, provided by nurses with higher qualifications and expertise, and feel more comfortable when they see the continuous presence and control of the nurse. In this regard, the results of Dehghan Nayeri et al. (2015) in Iran showed that the inability of nurses to properly manage and coordinate family participation in care activities can cause contradictions in the expectations of the role and involvement of the family in an unsafe and stressful activity.[3] The results of a qualitative study Jouybari et al. (2005) in investigating the experiences and viewpoints of the patients, hospitalized in Iran, regarding the comforting nurses showed that the nurses who provided care with technical competence were better relievers. Additionally, according to patients' viewpoints, the most important caring behaviors were nurses' availability and their close watch on the patients, which were in line with the findings of the present study.[24]

The process-based care competence category includes nurses' ability to provide care in form of the nursing process. In previous studies, competencies similar to the present study have been considered. For example, according to the Hartford Institute's gerontological nursing competencies tool, the competencies of nurses in the hospital include: communications; physiological and psychological age changes; pain skin integrity; functional status (such as overall function, urinary incontinence, nutrition/hydration, falls and injuries); restraints; elder abuse; and discharge planning.[25] In addition, AACN published 19 gerontological nursing competencies as the essentials for baccalaureate nursing education. Some findings of this study align with the overview of the competencies, such as identification and appropriate referral of potential elders' abuse; providing restraint-free care (both physical and chemical restraints); using valid and reliable assessment tools to guide nursing practice for older adults; identify and manage geriatric syndromes; and facilitate ethical, non-coercive decision making by older adults and/or families/caregivers.[26]

The category of self-care and continuous professional development competence indicates the value of health and nurses' holistic self-care in gerontological nursing care, which is consistent with the findings of Benadé et al. (2017).[27] Additionally in other studies, recognition of nurses' own learning needs, self-awareness about their professional strengths and weaknesses, and nurses' coaching role in improvement of others' professional development were mentioned as nurses' key competencies.[28]

The qualitative approach to this study limits the generalizability of the findings. In addition, the gerontological nursing competence has been studied depending on the experiences of nurses, nursing managers, and clinical educators; therefore, it is recommended that future studies examine the opinions of the elderly and their caregivers and families.

Conclusion

The current study explains the competencies required for nurses to provide better care of older people. Extracted categories highlight several important aspects of these competences. By identifying these competencies, nursing managers and instructors will be able to design and implement their managerial and educational activities to develop gerontological nursing competence.

Financial support and sponsorship

Isfahan University of Medical Sciences and Arak University of Medical Sciences

Conflicts of interest

Nothing to declare.