Introduction
At the end of 2019, Taiwan had 3,607,127 citizens and residents aged 65 years and above, accounting for 15.28% of the country's total population (Ministry of Interior, Taiwan, ROC, 2020). In 2019, older adults occupied over one third (37.2%) of acute care hospital beds and accounted for 45.9% (roughly USD$30 billion) of all inpatient expenses covered by Taiwan's national health insurance program (Ministry of Health and Welfare, Taiwan, ROC, 2021). Older adults have unique and complex care needs that span the medical, cognitive, emotional, social, and environmental domains. Moreover, their signs and symptoms for various illnesses may differ markedly from those of other age groups, requiring nurses to have specialized training and education (St. Pierre & Conley, 2018).
Observing the rapid increase in the world's aging population, leaders in geriatrics/gerontology nursing recognize the unique need to ensure that nurses have sufficient capabilities in geriatric care. Therefore, specific core competencies have been identified for gerontological nursing in addition to those required for the general nursing profession. The American Association of Colleges of Nursing (AACN) and the John A. Hartford Foundation Institute for Geriatric Nursing at New York University assembled inputs from qualified gerontological nursing experts into the Recommended Baccalaureate Competencies and Curricular Guidelines for Geriatric Nursing Care in 2008 (AACN, 2008). These geriatric care competencies were updated in 2010 to include 19 statements that are important in ensuring accessible, quality nursing care for older adult populations (AACN, 2010).
The acute care hospital is often the point of entry into the healthcare system for older adults. Nurses make up the largest contingent within healthcare teams, and working in hospitals is likely to include care for older patients even if a nurse is not assigned to a geriatrics unit. A working knowledge of geriatric care competencies is necessary for nurses to provide high-quality care to older patients and their families. Still unclear are how nurses working in acute care hospitals self-evaluate their geriatric care competencies and how significant is the difference between their self-evaluation and their objective ability in these competencies. Therefore, the aim of this study was to explore the geriatric care competencies of nurses in hospitals and to identify the associated factors.
Methods
Setting and Participants
Between April 1 and December 31, 2016, a descriptive correlational study was conducted in all of the adult wards of a 1,135-bed tertiary care medical center in southern Taiwan. Inclusion criteria were nurses employed at the hospitals and directly caring for patients aged 65 years and older. Nurses who had been employed less than 3 months or were holding administrative positions were excluded. The sample numbers were calculated using G*Power 3.1.9.2. Estimation was based on the Cheng et al. (1996) study, in which all variables explained 11.6% of the ability of public health nurses to perform gerontological care. Other estimating parameters included the number of predictors (14), the probability of Type I error (0.05), and a power of 0.8. It was estimated that at least 152 nurses were required for this study. An additional 10% margin was added to this number to account for the possibility that some nurses would not complete the questionnaire, increasing the total sample needed to 170.
Using quota sampling, 170 nurses from adult wards were enrolled as participants. The number of nurses in each ward was separately measured by considering the number of the required sample for this study (170) and comparing the ratio of the number of older patients in the ward with the total number of older patients in the hospital (the number of nurses in the ward was 170 multiplied by the number of older patients in the ward divided by the total number of older patients in the hospital). The study was approved by the medical center's institutional review board (B-ER-104-274). Informed consent was obtained from each participant before enrollment.
Measurements
Self-Report Questionnaire
The questionnaire included four parts: demographic characteristics, knowledge of geriatric care scale, attitude of geriatric care scale, and self-evaluation of competencies to provide geriatric care (SCG).
1. Demographic characteristics: The demographic data collected consisted of age, highest level of education, years of experience as a registered nurse, work unit, job satisfaction (1 = very dissatisfied, 2 = dissatisfied, 3 = neutral, 4 = satisfied, and 5 = very satisfied), perception of importance of work (1 = not important at all, 2 = not very important, 3 = neutral, 4 = important, and 5 = very important), perception of comfort in the work environment (1 = very uncomfortable, 2 = uncomfortable, 3 = neutral, 4 = comfortable, and 5 = very comfortable), family support (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree), having received geriatric-related education in school, and having received continuing education on geriatric care.
2. Knowledge of geriatric care scale: This scale was developed and published in Chinese in 2009. It comprises 50 items and addresses four domains: aging-related statistics and management of biological aging, physiological aging, and psychosocial aging. The total possible score range is from 0 to 50, with incorrect and "do not know" responses earning 0 points and each correct response earning 1 point. The Cronbach's alpha coefficient, representing the questionnaire's internal consistency reliability, was .62. The questionnaire's content validity index was .92 (Ho, 2009).
3. Attitude of geriatric care scale: This scale was also developed in Chinese in 2009. The questionnaire comprises 23 items (12 positive and 11 negative), rated on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). The 11 negatively worded items are reverse scored. The total possible score range is from 23 to 92, with higher scores indicating more positive attitudes. The Cronbach's alpha coefficient was .84, and content validity index was .79 for this scale (Ho, 2009).
4. SCG: The SCG was developed by the research team based on the AACN statements of geriatric care competencies and Roethler et al. (2011). This scale consists of 25 statements scored using a 4-point Likert scale ranging from 1 (not at all confident) to 4 (very confident). The total possible SCG score range is from 25 to 100, with higher scores indicating more confidence in providing geriatric care. For this study, tests of content validity and jury opinion were performed with five experts, including two gerontological nursing professors, two gerontological clinical nurse specialists, and one geriatrician. The overall Cronbach's alpha coefficient was .87, indicating good reliability and validity.
Dichotomous Problem Checklist
A dichotomous (yes/no) problem checklist was designed by the research team from the SCG items used to assess the occurrence of common health problems, including activities of daily living (ADL) impairment, gait and balance disorder, delirium, depressive symptoms, cognitive impairment, pain, sensory deficit, polypharmacy, malnutrition, urinary incontinence, insomnia, and caregiver burden. ADL impairment was defined as dependence in any the items (i.e., bathing, dressing, visiting the toilet, getting up out of a chair, eating, use of incontinence materials) of the Katz ADL (Katz et al., 1963). The Timed Up and Go test is a validated and reliable measure of functional capacity incorporating aspects of mobility, strength, and balance and involves measuring the time taken (in seconds) for the patient to rise from a chair, walk a distance of 3 m, turn, and walk back to the chair. Patients who complete the test in more than 20 seconds are rated as having "gait and balance disorder" (Podsiadlo & Richardson, 1991). The Diagnostic and Statistical Manual of Mental Disorders criteria were used to describe "delirium" (American Psychiatric Association, 2013), which includes inattention, impaired consciousness, disturbance of cognition, and acute onset and a fluctuating course of symptoms. If two or more of these symptoms are reported, a determination of delirium is considered. Depressive symptom was defined as earning a total score of more than 8 on the Geriatric Depression Scale Short-Form (Yesavage & Sheikh, 1986). Cognitive impairment was defined as performing two or more errors after adjusting for educational level on the Short Portable Mental Status Questionnaire (Pfeiffer, 1975). For patients who were incompetent in responding, the Short Portable Mental Status Questionnaire was automatically coded as cognitive impairment. Sensory deficit was defined as the inability to read better than 20/40 on a Snellen chart or the inability to hear 1000 or 2000 Hz in both ears or either frequency in one ear (Moore & Siu, 1996). Polypharmacy was defined as the concomitant use of more than five medications (Rollason & Vogt, 2003). The mini-nutritional assessment is composed of 18 simple and rapid-to-measure items (anthropometric assessment, general assessment, dietary assessment, and subjective assessment), with scoring on each part categorizing the respondent as one of the following: well nourished, at risk for malnutrition, and malnourished (Guigoz et al., 1999). Urinary incontinence was considered in the affirmative if the respondent reported wetting themselves within the previous 2 weeks (Abrams et al., 2003). Insomnia was considered in the affirmative if the respondent reported experiencing persistent difficulties with sleep initiation, duration, consolidation, or quality resulting in daytime impairment (American Academy of Sleep Medicine, 2014). Caregiver burden was considered in the affirmative if the caregiver reported feeling overly strained or burdened by caring for older patients (Stucki & Mulvey, 2000).
Data Collection
The first author and two research nurses collected the data for this study. The consistency between these researchers was examined before data collection, and the interrater reliability was .98. The researchers visited the study wards Monday through Friday during the study period to recruit eligible nurses. After consent was obtained, phase I data collection used a self-report questionnaire (demographic characteristics, knowledge of geriatric care scale, attitude of geriatric care scale, and SCG), copies of which the researchers delivered to the participants.
After phase I data collection, the research nurses turned from subjective participant evaluation of their own knowledge and skills to objective evaluation of the health problems faced by older patients who received direct care from the participants. The researchers first evaluated the health problems of an older patient cared for by each nurse participant. Next, the researchers consulted the geriatrician or geriatric clinical nurse specialist to confirm those health problem evaluations. In the meantime, the researchers also provided a blank dichotomous (yes/no) problem checklist to each nurse participant with instructions to select/tick the health problems of that older patient. Using the results of the researchers' yes/no problem checklist as the gold standard, the geriatric care competency test (GCCT) compared the yes/no problem checklist of the research nurses with that of each participant. If the researchers had ticked an item as one of the older patient's health problems but the participant had not, the item was treated as "incorrect." Similarly, if the researchers had not ticked a certain health problem item but the participant ticked that item, the item was treated as "incorrect." All other situations were treated in this study as "correct."
Statistical Analysis
Statistical analyses were performed using SPSS for Windows, Version 20.0 (IBM Inc., Armonk, NY, USA). All p values were two-tailed, and p < .05 was considered statistically significant. Descriptive analyses were carried out to evaluate the demographic characteristics and geriatric care competencies of the nurse participants. The associations between participants' characteristics and geriatric care competencies were assessed as appropriate using Pearson's correlation analysis, independent samples t test, one-way analysis of variance, and chi-square test. Multiple regression analysis was performed to measure the variables associated with geriatric care competencies. Variables that were present in > 10% of the patients with p < .05 on univariate analysis were entered into the model for adjustment.
Results
Participants' Characteristics and Geriatric Care Competencies
The mean age of the participants was 27.64 years (SD = 7.28 years). Most (97.6%) held a bachelor's degree, and approximately three quarters (74.4%) had worked in the hospital for fewer than 5 years. Of this sample, the largest share (48.2%) worked in a medical ward, followed by surgical ward (28.2%) and general ward (23.5%). The participant characteristics are summarized in Table 1. Furthermore, 57.1% of the participants had received geriatric-related education in school, and 39.4% had received continuing education on geriatric care. The total mean score for knowledge about geriatric care was high, at 36.07 (SD = 4.44), and the mean score for attitude was medium-high, at 62.44 (SD = 5.28). The results for SCG are presented in Table 2. The mean score for participants was 67.74 (SD = 8.84), and the three categories with the lowest ratings were recognizing depressive symptoms, managing depressive symptoms, and providing dementia care.
In total, only 17.6% of the participants assessed all of the items on the GCCT correctly. The four items with the lowest correct rates were caregiver burden and insomnia (62.4%) and urinary incontinence and malnutrition (62.9%). The GCCT results are summarized in Table 3.
Relationship Between Nurse Characteristics and Geriatric Care Competencies
As shown in Table 4, the SCG score was shown to be significantly associated with job satisfaction (r = .300, p < .001), perception of importance of work (r = .181, p = .019), comfort in the work environment (r = .260, p = .001), family support (r = .190, p = .015), and having received continuing education on geriatric care (t = 1.949, p = .048). Moreover, multiple regression analysis showed that nurses with increased job satisfaction (adjusted [beta] = 3.35, 95% CI [0.28, 6.43]) who had received continuing education on geriatric care (adjusted [beta] = 2.81, 95% CI [0.13, 5.49]) earned significantly higher scores on the SCG. Other related variables, perception of importance of work, and comfort in the work environment and family support were not found to be significantly associated with SCG score.
The independent samples t test and chi-square test were also used to analyze the data. The findings revealed that only age significantly affected the number of correct answers given on the GCCT.
Discussion
This study was designed to explore the geriatric care competencies of nurses in hospitals. The influence of personal characteristics on geriatric care competencies was also examined. The participants self-evaluated as having a medium-high level of competency in providing geriatric care (SCG). However, the average percentage of correct answers on the GCCT was only 17.6%. These findings are consistent with other studies (De Almeida Tavares et al., 2015; Roethler et al., 2011). Roethler et al. showed a lack of congruency between nurses' knowledge about geriatric care and their self-perceived competency. All of the nurses rated themselves in their self-assessment as "very good" or "good" in their ability to provide geriatric care. However, only 32% answered 60% or more of the knowledge questions correctly. This may be because the competency information was self-reported. One dilemma inherent to this type of data collection is participant bias. The participants may have adjusted their ratings to what they thought the researcher wanted to hear. Moreover, they may have believed incorrectly that the study results would change or create new department policies concerning geriatric care and thus adjusted their responses accordingly. The findings emphasize that nurses may overrate their perception of their geriatric care competencies and thus require awareness of these discrepancies to enhance their competencies accordingly.
As no prior study has similarly applied an objective instrument of geriatric care competencies, no comparisons of the results may be made with previous studies. However, on the basis of the correct-answer rate of the GCCT, the participants scored particularly low for assessing caregiver burden and for distinguishing symptom differences among various types of insomnia. Wolf et al. (2019) reported that, whereas 50%-70% of older patients are screened routinely for cognitive impairment, depression, fall risk, malnutrition risk, and compromised ADL, far fewer (16.8%) are screened routinely for caregiver stress. De Almeida Tavares et al. (2015) also found that the knowledge scores and attitudes of nurses toward the management of sleep disorders were negative. An important barrier in assessing caregiver burden and insomnia is the level of related knowledge held by the nurse. The results presented here were not completely unexpected because of the lack of related continuing education and available specialization in geriatric care. Another barrier noted by the participants in this study was that lack of access to resources impedes providing related care for caregiver burden and insomnia, which are critical to providing appropriate care to older patients. Multicomponent interventions are suggested, including supplementing education with consultation (a clinical nurse specialist or an interdisciplinary team) and making more resources and support available from leadership to introduce interdisciplinary collaborators such as social workers or a sleep team.
This study found that increased job satisfaction and having received continuing education on geriatric care were significantly associated with earning a higher score on the SCG. These findings agree with the results of previous studies (Dahlke et al., 2019; Tzeng, 2004). Geriatric care education in the clinical setting is necessary and widely practiced. However, Dahlke et al. (2019) examined nurses' learning needs related to working with hospitalized older patients and found that nurses reported gaps in their clinical practice despite scoring moderately high on knowledge of geriatric care. It seems that having a moderately strong knowledge base from continuing education is not sufficient for nurses to provide high-quality care. Therefore, a systematic approach to improving nurses' geriatric care competencies is necessary to meet the demands of Taiwan's growing population of older adults. Currently, Taiwan has no certified geriatric nurses. Thus, appropriate policies are needed to improve the geriatric care competencies of nurses in hospitals, implement effective educational methods and structures, and realize an evidence-based, geriatric clinical practice. With the exception of nurse age, this study did not find any significant association between participant demographic characteristics and GCCT scores. Nurse age does not explain the nurses' objective test of geriatric care competencies. Further research is warranted to explore the factors associated with the GCCT.
This study was affected by several limitations. First, the research was conducted at one hospital only, which prevents generalizing the results to the larger population of hospital nurses. Second, the GCCT compared the dichotomous problem checklist between the research nurses and the participant nurses, which may have affected the accuracy of problem identification. The authors attempted to address this limitation by consulting the geriatrician or geriatric clinical nurse specialist to confirm the health problems of each older patient addressed in this study.
Conclusions
The number of older patients treated in hospitals is expected to increase dramatically in the future. Nurses who work in hospital settings should have solid geriatric care competencies to improve their practice and to impact positively on the healthcare outcomes of their older patients. The subjective and objective evaluations of the geriatric care competencies of nurses in hospitals is an issue that has been rarely addressed in previous studies. The findings of this study provide evidence that nurses are insufficiently aware of their limitations in terms of knowing how to provide appropriate care to older patients. These findings suggest that policies to improve the geriatric care competencies of nurses in hospitals and to oversee the implementation of effective educational methods are needed in Taiwan. Furthermore, more research is needed to evaluate geriatric care competencies using patient outcomes (e.g., incidence of mortality, functional decline, hospitalization hazards).
Acknowledgments
This study was supported by National Cheng Kung University Hospital (NCKUH-10501004). The funding source had no involvement in the research process.
Author Contributions
Study conception and design: FWH, FAL
Data collection: FWH, FAL
Data analysis and interpretation: FWH, YPL
Drafting of the article: FWH
Critical revision of the article: FAL, YPL
References