UK frameworks

Gerontological nursing is recognised nationally and internationally as a postgraduate nursing specialty. However, there is a lack of consensus on standardised competencies and education development, particularly in the UK. The NMC (2018) standards of proficiency for registered nurses apply across all fields of nursing practice and all care settings, but there is no national certification in gerontological nursing and the NMC has not endorsed curricula at post-registration level. This contrasts with countries such as the US, where there has been substantial development of competencies in care of the older person, leading to certification in gerontological nursing (American Association of Colleges of Nursing and Hartford Institute for Geriatric Nursing 2010).

In the UK, there have been several attempts to progress the specialty over the last ten years. For example, Pearson et al (2015) developed a National Career Framework for Nurses for Older People with Complex Needs in England. The framework provides prompts to enable nurses to identify their learning needs but does not articulate specific competencies related to their level of expertise.

As part of a programme to prepare advanced nurse practitioners in gerontological nursing, Goldberg et al (2016) developed a framework consisting of 49 essential competencies. Similarly, Stanyon et al (2017) identified 22 competencies specifically for care home nurses which describe the unique needs of older people in this setting. The competency areas broadly cover items such as practical clinical skills, management and leadership, quality improvement and team working.

International frameworks

Globally, there are concerns about the preparedness of the health and social care workforce, including nurses, to provide age-attuned care, which has resulted in a growing number of articles identifying the need to articulate and appraise gerontological competencies (Stanley and Alesandrini 2004, Bing-Jonsson et al 2015, Karlstedt et al 2015, Goldberg et al 2016, Boscart et al 2017, Dijkman et al 2017, Stanyon et al 2017, Kiljunen et al 2018, Chen et al 2019).

In a European context, a collaboration involving 17 countries produced the European Core Competences Framework for Health and Social Care Professionals Working with Older People (Dijkman et al 2017). The framework describes seven roles and competences, expert (focused on physical care), communicator, collaborator, organiser, health and welfare advocate, scholar and professional. Meanwhile, in the context of care homes, Kiljunen et al (2018) focused on a range of skills and tasks that described competencies under four main themes: practice, skills, attitudes and ethics.

In the US, work supported by the Hartford Institute and the Nurses Improving Care for Healthsystem Elders programme developed a framework for gerontological nurse competence that identified 27 domains focusing on physical, mental and functional health, common geriatric conditions, carers, coordinating care, interprofessional working and education (Stanley and Alesandrini 2004).

Step 1: review of existing frameworks

The review of the national and internationally developed frameworks referred to previously identified the following core domains regarding the knowledge and skills required for competence in nursing older people:

These core domains were integrated with the CGA model and organised into ten competency domains, with clinical leadership included as an essential attribute of successful interdisciplinary working and older adult advocacy. Competency statements, which were adapted from the literature and appropriate to gerontological practice for early career nurses, were also developed. The competency statements are not situation specific to provide flexibility for students when identifying their personal learning goals in caring for older adults in their service. Initially 80 competency statements were formulated and later reduced to 69. Table 1 outlines the module learning outcomes and competency domains and includes examples of competency statements.

The education module learning outcomes and content reflect the ten domains. The module was delivered using a flipped learning classroom model (Bergmann and Sams 2014), combining six face-to-face study days over six months with online learning, clinical visits and mentorship in practice. As students progressed through the theoretical knowledge underpinning each domain, the in-class workshops provided opportunities for shared learning, case study presentation and reflection on application of CGA in practice.

Step 2: face and content validity testing

Face and content validity testing of the competency framework were conducted at local and national level, engaging expert groups and stakeholders in co-production workshops. In the first instance, a co-production workshop was held with a local expert group of ten senior hospital-based nurses from clinical practice and education practice development, who agreed that the structure and domains were valid. Minor areas for clarification were identified in three domains and competency statements.

In a second workshop with private and public care home manager stakeholders, there was consensus that the competencies were valid for caring for older people in nursing and residential care.

Finally, there was universal agreement on the face validity of the domains for acute, community and long-term care settings. This means that the experts and stakeholders agreed that the competencies reflected accurately what early career nurses can be expected to demonstrate in practice.

Step 3: review of draft competencies

The draft competencies were reviewed at a workshop and by email by 14 members of the BGS Nurse and Allied Health Professions Special Interest Group (now replaced by the BGS Nurse and Allied Health Professional Council). This resulted in further minor adjustments and clarifications, including recognition of carers’ diverse needs, and resulted in the final list of 69 competency statements.

Step 4: application in practice

Students sought a clinical mentor – usually a ward manager or practice development nurse – to support their completion of the competency framework and demonstrated achievement through written narratives and discussions with their mentor. It was expected that students and their mentors would meet on three or four occasions over the six-month duration of the module. Individual competency statements could also be signed by allied health professionals or specialist nurses, for example clinical nurse specialists in palliative care.

Aim

To evaluate a competency framework for early career nurses undertaking post-registration education in a UK university in care for older people living with frailty.

Method

The evaluations took place between June 2018 and May 2019. A mixed-methods approach was used involving online surveys, one-to-one interviews and focus group interviews with students, mentors, ward managers and care home managers. Only the evaluation data specific to the competency framework are reported in this article. A bespoke survey was designed, as part of the evaluation of the competency framework, students’ contact with mentors and supplemental learning days, based on a five-point Likert scale (1=strongly disagree to 5=strongly agree). Focus group interviews with students were held and recorded on the final module study day, while one-to-one interviews were conducted with mentors and ward managers following completion of the module. Descriptive thematic analysis as described by Braun and Clarke (2006) was used to identify themes.

Completion of competency portfolio

Of the 46 students recruited to the ECHO and PEACH interventions, 33 submitted and passed the competency portfolio (ECHO n=23, PEACH n=10) and 30 participated in the evaluation (ECHO n=23, PEACH n=7). When reviewing the portfolios, it was found that nine out of the ten domains were completed. The exception was the end of life domain which students working in community or specialist acute hospital teams did not have the opportunity to complete.

There was variation in the degree to which students’ reflective narratives and mentor comments were completed, but where portfolios were completed adequately, mentors affirmed the student’s progress over the six months. Their comments included the following:

‘[Name] demonstrates a passion for the care of older people.’

‘[Name] has grown in confidence and demonstrated strong clinical leadership.’

Survey data

Of the 30 students who participated in the evaluation, 27 completed the survey (ECHO n=23, PEACH n=4). Table 3 shows students’ survey responses, reported in median values and interquartile range. Students’ responses showed that they found the competency framework useful, that it aligned well with the theoretical module and that it helped to bridge the gap between theory and practice. In general, students found the competency statements easy to understand, but noted there was some duplication that could be reduced and identified the need for mentor preparation.

Focus group interviews

Of the 30 students who participated in the evaluation, 28 took part in focus group interviews. There was one PEACH focus group (focus group 1, n=7) and two ECHO focus groups (focus group 2, n=10, focus group 3, n=11). The focus group data confirmed findings from the survey data, in that the competency framework was acceptable to the students and there was consensus that the competencies confirmed ‘what they knew already’ and identified areas they needed to develop. For example, one student commented:

‘I realised that some of those competencies were things that I should have been doing as a nurse which I didn’t realise I was not doing. So, for me it’s really an eye opener for me, some of the competencies.’ (PEACH student, focus group 1)

The themes generated from the data collected during the focus group interviews were organised under two broad headings - benefits and challenges. There were three subthemes under benefits, unique knowledge, affirmation and expanded insights.

Mentor evaluation

Three mentors were interviewed and their views reflected those of the students. The mentors were positive about the reflective portfolio as part of the wider intervention but said they would have liked further preparation and support. For example, one mentor commented:

‘I think that [the competency framework and reflective portfolio] was good. Each of [the education-career components] complemented each other and brought the things, brought it together, and I think it was nice for [student] to see different practice and I think the networking within the group he really liked as well.’

Service user feedback

Indirect feedback from service users was obtained from optional entries in students’ reflective portfolios. The feedback from older people focused on the students’ competence and quality and was positive. For example, one service user said:

‘She listened well, she provided me with great care and persuasion. Overall, she is a wonderful nurse and I wish there were more nurses like her. She made sure my medication was correct and given on time, very compassionate and understanding.’

Limitations

A range of stakeholders was consulted during the project, but there was no direct engagement with older adult service users when developing the competencies, although service user feedback was encouraged as part of the students’ reflective portfolios. The project also involved a small number of participants across a range of organisations, so it was beyond its scope to demonstrate its effects on patients and residents or to infer causality.

The competency framework requires further testing and refinement to ensure its applicability across geographical regions and other older adult services and to address patient outcome measures.