Geriatric Nursing xx (2014) 1e6
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Retooling the RN workforce in long-term care: Nursing certification as a pathway to quality improvement Mary E. Cramer, PhD, APHN-BC, FAAN a, *, Robin High, MBA, MA b, Beth Culross, RN, GCNS-BC, CRRN a, Deborah Marks Conley, MSN, APRN-CNS, GCNS-BC, FNGNA c, d, Preethy Nayar, MD, PhD b, Anh T. Nguyen, MSPH b, Diptee Ojha, MBA, BDS b a
College of Nursing, University of Nebraska Medical Center, Omaha, NE 68198, USA College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA Nebraska Methodist Hospital, Omaha, NE, USA d Nebraska Methodist College of Nursing, Omaha, NE, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 September 2013 Received in revised form 6 January 2014 Accepted 9 January 2014 Available online xxx
This article describes a project to improve nursing care quality in long-term care (LTC) by retooling registered nurses’ (RN) geriatric clinical competence. A continuing education course was developed to prepare LTC RNs (N ¼ 84) for national board certification and improve technological competence. The certification pass-rate was 98.5%. The study used a mixed methods design with retrospective pretests administered to RN participants. Multivariate analysis examined the impact of RN certification on empowerment, job satisfaction, intent to turnover, and clinical competence. Results showed certification significantly improved empowerment, satisfaction, and competence. A fixed effects analysis showed intent to turnover was a function of changes in empowerment, job dissatisfaction, and competency (F ¼ 79.2; p < .001). Changes in empowerment (t¼1.63, p¼.11) and competency (t¼-0.04, p¼.97) did not affect changes in job satisfaction. Findings suggest RN certification can reduce persistently high RN turnover rates that negatively impact patient safety and LTC quality. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: Evaluation Long-term care Nursing homes Nursing studies Workforce issues
Introduction The aging of America continues to present a crisis for the geriatric health care workforce. Currently, 13% of the US population is older than 65 years and this percentage will increase to nearly 20% by 20301 e creating a burgeoning demand for qualified workforce especially for long-term care (LTC) facilities whose services range from assisted living to nursing homes to other residential care facilities. While relatively few seniors aged 65þ (4.1%) currently reside in nursing homes this percentage rises sharply with age to 13.2% for those 85þ years.1 These demographic forces coupled with the fact that today’s nursing homes have become the new hospitals providing more acute rehabilitation for patients too ill to return home after hospital discharge will challenge the LTC industry to better prepare their
* Corresponding author. Tel.: þ1 402 559 6617; fax: þ1 402 559 6379. E-mail address: [email protected] (M.E. Cramer). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.01.001
nursing workforce. Moreover, the aging baby boomers that comprise a large proportion of the LTC market-share have grown accustomed to high standards of quality health care, and there is little reason to believe these graying boomer consumers will expect anything less than the best from their LTC facilities and health providers as they age. In 2008, the Institute of Medicine (IOM) focused national attention on the geriatric health care workforce crisis in Retooling for an Aging America: Building the Health Care Workforce.2 Key recommendations included the need to boost recruitment and retention of the geriatric workforce and to train more health care providers in the basics of geriatric care. The report called for incentives to attract and retain a more qualified and betterprepared geriatric workforce, as well as to provide greater professional recognition and salaries for geriatric specialists and nurses. A primary precept of the study was the inadequate clinical preparation of our current geriatric workforce e including nurses e in having the necessary competencies to care for the older adult. Indeed, the report recommended that health care professionals should be required to demonstrate their
2
M.E. Cramer et al. / Geriatric Nursing xx (2014) 1e6
competency in geriatric care as a criterion of licensure and certification. In 2011, the IOM issued another seminal report entitled, The Future of Nursing: Leading Change, Advancing Health that envisioned a role for how nursing, the largest segment of the health care workforce, could lead the transformation of quality health care in the United States. One of this report’s key recommendations is need for “. all health care organizations to ensure that nurses continue their education and engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan.”3(p282) The purpose of this article is to describe the outcomes and impact of a geriatric workforce research project that was designed to meet the challenge of retooling a more highly qualified LTC RN workforce through national board certification in care of the older adult. Background Perhaps no other industry has a greater stake in promoting a qualified geriatric nursing workforce than LTC. Long-term care is a major employer and economic driver in the US. It ranks 10th in jobs with over 2 million workers, represents 1.3% of the nation’s gross domestic product, and generates $529 billion in economic activity $60 billion in state and federal tax revenues each year.4 But LTC has been slow to respond to the IOM2,3 retooling recommendations to recruit, retain, and incentivize a more highly educated nursing workforce, which is evidenced by the lowest nurse retention rates (49% for all categories)5 of any health care settings (e.g., hospital, clinic, etc). The RN role in LTC is important for a stable, positive nurse work environment and quality care. Certified nursing assistants provide the preponderance of direct patient care in LTC. However, it is the registered nurse (RN) that supervises, directs, delegates, mentors, trains, and evaluates the overall delivery of total nursing care. Indeed, the level of RN staffing in nursing homes e as opposed to licensed practice nurse staffing e is predictive of organizational quality care indicators including fewer total deficiencies, fewer quality of care deficiencies, fewer serious deficiencies, and fewer lawsuits.6e8 But LTC RNs do not remain in their positions for very long. There have been persistently high RN turnover (42.8%) and high RN vacancy rates (10%)5 in LTC and these factors have contributed to lingering image problems, stressful work environments, lowered job satisfaction, and even concerns for patient safety and quality care.9,10 Together, these poor RN workforce indicators have been an economic drain for the industry in terms of the associated costs of RN replacement. The most recent estimates for RN turnover are calculated at $82,006e$88,032 per nurse,11 which includes costs for pre-hire (i.e., recruitment, vacancy coverage, hiring processes) and post-hire (orientation/training, new-hire productivity, pre-turnover productivity, termination).12,13 There is also some concern that most RNs e especially in LTC e may not be fully prepared through their educational curricula to care for the gerontological patient, which may also contribute to the LTC issues of high RN turnover and low retention. Only about 50% of baccalaureate degree nursing programs include a dedicated course for gerontological nursing care in their curricula.14e16 The preponderance of LTC RNs e nearly three-fourths e are associate degree graduates who are even less likely to have had specific gerontological nursing coursework in their 2-year program e making the issue of an underprepared geriatric RN workforce in LTC even more compelling.17 Studies conducted in acute care settings show that patient outcomes improve when older adults are cared for by RNs who have gerontological education.18e22 The measure of nursing
excellence for RNs is national board certification in a clinical specialty, which has been shown to improve inpatient mortality and failure to rescue.23 In addition, job satisfaction increases for LTC RNs who have participated in continuing education.24 The American Nurses Credentialing Center (ANCC) offers a clinical certification, Gerontological Nursing, for RNs who care for older adult patients.25 Earning this certification confers the credentials of “RNBC.” Nationally only 1% of RNs are board certified in this clinical specialty,14 which may be linked to the fact that clinical specialty certification is not easily attained. For example, RNs seeking Gerontological Nursing certification must demonstrate the equivalent of 2 years full-time practice with at least 2000 h in gerontological nursing within the last 3 years, and 30 h of continuing education in gerontological nursing within the last 3 years. The certification exam fees are $395 and it is a rigorous test with an 85% national pass rate.26 In addition, the exam is administered at an official test site, which may be challenging for RNs living in rural communities. Another barrier has been the lack of incentives for LTC RNs. Without employer support (i.e., paid time, assistance with course or exam fees, flexible work schedules) or workplace incentives (i.e., increased pay, job responsibility, or promotion) few LTC RNs have been motivated to pursue clinical certification as a means of enhancing competency. In 2009, an academic medical center collaborated with 13 Midwestern businesses representing 60 long-term care facilities on a match grant. The academic/community partnership used a community-based participatory research (CBPR) approach to develop, implement, evaluate and disseminate the project, whose primary goal was to retool the LTC RN workforce through national certification education in Gerontological Nursing. A corollary goal was to improve LTC RNs’ technological competency for life-long learning skills so that once certified, these LTC RNs would be capable of maintaining their credentials through computer-based research, evidence based practices, and on-line continuing education. Yet another goal was to develop a distance education course for LTC RNs that was a satisfactory learning model. Before enrolling in the Gerontological Nursing course, RN participants and their employers signed contracts in which RNs agreed to complete weekly assignments in a timely manner, preregister for the national certification examination, share costs of the exam fee, and commit to taking the national certification exam. Employers agreed to share in at least 50% of the certification exam fees. The hypothesis for this CBPR project was that Gerontological Nursing certification education would improve RN clinical competency, job satisfaction, intent to turnover, and empowerment. The associated research questions were: (1) Does certification education change participants’ empowerment, job satisfaction, and clinical competency over time?; (2) Are changes in RN intent to turnover associated with changes in RN empowerment, job satisfaction, and competency over time?; (3) Do RN empowerment and competency affect job satisfaction?; and (4) Do RN supervisors assess improved clinical competency among participants? Two corollary questions for this CBPR project were to determine if RN participation in distance education was a satisfactory experience and improved RN computer technology skills. The University of Nebraska Medical Center Institutional Review Board approved the study. The authors utilized a mixed methods approach using qualitative and qualitative methods to conduct a process and outcomes evaluation of the project. The data set provided responses to multiitem surveys from which scales were computed describing the study’s key outcome measures for empowerment, job satisfaction, intent to turnover, and competency among RN participants who had completed the project’s educational course.
M.E. Cramer et al. / Geriatric Nursing xx (2014) 1e6 Table 1 Gerontology nursing course participation, completion, and certification.
Table 2 Instrument coefficient alphas for study sample responses.
Cohort # Invited # Enrolled # Completed (%) # Dropped out (%) # Passed (%) Gero 1 24 Gero 2 28 Gero 3 25 Gero 4 23 Total 100
24 28 25 23 100
20 22 19 22 83
(83.3) (78.6) (76.0) (95.7) (83.0)
4 6 6 1 17
(16.7) (21.4) (24.0) (4.3) (17.0)
20 22 16 11 69
(100.0) (100.0) (94.1) (100.0) (98.5)
Methods Sample The unit of study was RNs employed in LTC facilities that had completed the project’s educational course. A list of RNs (N ¼ 100) was obtained and selection criteria included current employment in one of 63 LTC facilities owned by the project’s five LTC business partners and RN interest in participation. One hundred LTC RNs enrolled in the educational course that was taught twice per year. The overall attrition rate during the two-year project was 16.0% (16 out of 100) (see Table 1). The reasons that RNs left the course before completion included employment resignation (n ¼ 5), personal or non-specified issues (n ¼ 5), and not enough time (n ¼ 6). The final sample that completed the course was N ¼ 84 RNs. Measures The key outcomes evaluated included empowerment, job satisfaction, intent to turnover, clinical competency, technological skills, and course satisfaction. We used a retrospective pretest methodology to administer surveys at a single point in time after program completion. Participants rated the level of change that occurred because of their participation (e.g., “Before I participated in this course, my level of knowledge was. After participating in this course, my level of knowledge is..). Evidence shows that the retrospective pretest methodology produces more accurate selfassessments of program outcomes than the traditional pretest/ posttest, which is administered at two separate points in time and often results participants underestimating the program’s impact on their changed knowledge, attitudes, and practices or behavior.26 Clinical competency was measured using the 31-item Hartford Geriatric Competency Tool,27 which evaluates eight domains: communication, physiological and psychological age changes, pain, skin integrity, functional status, restraints, elder abuse, and discharge. Our participants self-rated their level of clinical competency before and after course participation. We also sent the instrument to the participant’s supervisor and asked him/her to rate the participant’s clinical competency before and after program participation. Job satisfaction was measured with a 5-item instrument, General Job Satisfaction Scale, which was derived from the theoretical and conceptual work that resulted in the Job Diagnostic Survey.28,29 The measure for RN turnover, Intent to Turnover Scale, was a 3-item instrument from Cammann, Fichman, Jenkins, and Klesh.30 We measured empowerment using the 12-item Psychological Empowerment Instrument31 that focuses on RN perceptions of formal and informal power, participation in decision-making, control over practice, leadership within the health facility, and recognition of expertise by others. To measure RN technological competency and course satisfaction we developed two instruments specifically for our project. The 6-item instrument, Technology Skills Survey, assessed participant ability to perform specific technological tasks for on-line learning (e.g., computer-based web searches, literature searches, etc) before and after course participation using a 5-level ordinal response set
3
Psychological empowermenta Job satisfactionb Intent to turnoverc
Before
After
0.87 0.67 0.11
0.89 0.75 0.07
Before
After
0.76 (remove #3)
0.65 (remove #3)
a The 12 items were reverse coded. Four subscales were computed from three items each with “empowerment” being the average of the four subscales. b Job satisfaction had 5 items and there was reverse coding for items 1, 3, and 4. c Intent to turnover was computed from 3 survey items with no reverse coding.
from strongly agree to strongly disagree. Three content experts reviewed the instrument for face validity but no reliability or validity testing was done. The 5-item Satisfaction Survey included one item for overall satisfaction and four open-ended items: (a) how participants intended to use the information gained, (b) what changes participants expected to see in their LTC facility because of their certification, (c) what suggestions participants had for course improvement, and (d) what participants identified as the best experiences in the course. Three nursing faculty reviewed the instrument for face validity but no reliability or validity testing was done. Procedures We mailed surveys to N ¼ 84 RNs approximately 4e6 weeks after they had completed the educational course. To maximize our response rates, we used the Dillman-tailored design method that requires up to four contacts.32 First, we sent an advance email to our participants explaining the purpose of our study and the importance of completing the surveys. Approximately one week later we sent packets containing the cover letter, the instruments and a self-addressed envelopes. An email reminder was sent to RN participants five days later to encourage them to complete and return the surveys. Non-respondents received a second packet with the cover letter, surveys and self-addressed envelopes approximately two weeks after the email reminder. The final response rate was 72.6% (61 out of 84). Analyses We computed the instrument coefficient alphas for each of the scales for both pre- and post- course completion based on our study sample respondents. A composite score for Psychological Empowerment scale (see Table 2) was computed from the average of the instrument’s four subscales. The Job Satisfaction scale was reverse coded for 3 of the 5 items and a composite score computed for an average (see Table 2). The intent to turnover alphas were greatly improved when the third item of the scale was removed; thus, the score was computed from an average of 2 of the 3 items (see Table 2). It might be conjectured that the third item of the scale that was removed (“How likely is it that you could find a job with another employer with about the same pay and benefits you have now?”) may reflect more on the profession of nursing itself. In other words, it may not have the same assumed relationship to the first two variables that it does for the other professions for which this scale was developed. Improved results for the Hartford Competency scale were achieved with a weighted average of a subset of the subscales for physiological and psychological, functional status, restraints, and discharge planning. Thus, the overall competency measure was computed on only these 4 subscales (see Table 3). We computed measures at two time points labeled as pre- and post-participation. To examine research questions 1, 2, and 3 there were two responses collected from each participant. For the first
4
M.E. Cramer et al. / Geriatric Nursing xx (2014) 1e6
Table 3 Individual alphas for seven subscales of Hartford Competency based on sample responses.
Table 5 Change in intent to turnover as a function of empowerment, job dissatisfaction, and competency.
Scale
No. of items
Before
After
Scale
DF
Estimate
Standard error
t-value
p-value
Communication Physiological & psychological age changesa Pain Skin integrity Functional statusa Restraintsa Elder abuse Discharge planninga
4 7 3 2 8 3 1 3
0.61 0.76 0.80 0.31 0.85 0.91 e 0.23
0.025 0.60 0.04 0.03 0.39 0.91 e 0.67
Empowerment Job dissatisfaction Competency Time
1 1 1 1
0.161 0.429 0.137 0.23
0.111 0.034 0.314 0.119
1.45 12.6 0.44 1.92
0.15
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Retooling the RN workforce in long-term care: Nursing certification as a pathway to quality improvement Mary E. Cramer, PhD, APHN-BC, FAAN a, *, Robin High, MBA, MA b, Beth Culross, RN, GCNS-BC, CRRN a, Deborah Marks Conley, MSN, APRN-CNS, GCNS-BC, FNGNA c, d, Preethy Nayar, MD, PhD b, Anh T. Nguyen, MSPH b, Diptee Ojha, MBA, BDS b a
College of Nursing, University of Nebraska Medical Center, Omaha, NE 68198, USA College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA Nebraska Methodist Hospital, Omaha, NE, USA d Nebraska Methodist College of Nursing, Omaha, NE, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 September 2013 Received in revised form 6 January 2014 Accepted 9 January 2014 Available online xxx
This article describes a project to improve nursing care quality in long-term care (LTC) by retooling registered nurses’ (RN) geriatric clinical competence. A continuing education course was developed to prepare LTC RNs (N ¼ 84) for national board certification and improve technological competence. The certification pass-rate was 98.5%. The study used a mixed methods design with retrospective pretests administered to RN participants. Multivariate analysis examined the impact of RN certification on empowerment, job satisfaction, intent to turnover, and clinical competence. Results showed certification significantly improved empowerment, satisfaction, and competence. A fixed effects analysis showed intent to turnover was a function of changes in empowerment, job dissatisfaction, and competency (F ¼ 79.2; p < .001). Changes in empowerment (t¼1.63, p¼.11) and competency (t¼-0.04, p¼.97) did not affect changes in job satisfaction. Findings suggest RN certification can reduce persistently high RN turnover rates that negatively impact patient safety and LTC quality. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: Evaluation Long-term care Nursing homes Nursing studies Workforce issues
Introduction The aging of America continues to present a crisis for the geriatric health care workforce. Currently, 13% of the US population is older than 65 years and this percentage will increase to nearly 20% by 20301 e creating a burgeoning demand for qualified workforce especially for long-term care (LTC) facilities whose services range from assisted living to nursing homes to other residential care facilities. While relatively few seniors aged 65þ (4.1%) currently reside in nursing homes this percentage rises sharply with age to 13.2% for those 85þ years.1 These demographic forces coupled with the fact that today’s nursing homes have become the new hospitals providing more acute rehabilitation for patients too ill to return home after hospital discharge will challenge the LTC industry to better prepare their
* Corresponding author. Tel.: þ1 402 559 6617; fax: þ1 402 559 6379. E-mail address: [email protected] (M.E. Cramer). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.01.001
nursing workforce. Moreover, the aging baby boomers that comprise a large proportion of the LTC market-share have grown accustomed to high standards of quality health care, and there is little reason to believe these graying boomer consumers will expect anything less than the best from their LTC facilities and health providers as they age. In 2008, the Institute of Medicine (IOM) focused national attention on the geriatric health care workforce crisis in Retooling for an Aging America: Building the Health Care Workforce.2 Key recommendations included the need to boost recruitment and retention of the geriatric workforce and to train more health care providers in the basics of geriatric care. The report called for incentives to attract and retain a more qualified and betterprepared geriatric workforce, as well as to provide greater professional recognition and salaries for geriatric specialists and nurses. A primary precept of the study was the inadequate clinical preparation of our current geriatric workforce e including nurses e in having the necessary competencies to care for the older adult. Indeed, the report recommended that health care professionals should be required to demonstrate their
2
M.E. Cramer et al. / Geriatric Nursing xx (2014) 1e6
competency in geriatric care as a criterion of licensure and certification. In 2011, the IOM issued another seminal report entitled, The Future of Nursing: Leading Change, Advancing Health that envisioned a role for how nursing, the largest segment of the health care workforce, could lead the transformation of quality health care in the United States. One of this report’s key recommendations is need for “. all health care organizations to ensure that nurses continue their education and engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan.”3(p282) The purpose of this article is to describe the outcomes and impact of a geriatric workforce research project that was designed to meet the challenge of retooling a more highly qualified LTC RN workforce through national board certification in care of the older adult. Background Perhaps no other industry has a greater stake in promoting a qualified geriatric nursing workforce than LTC. Long-term care is a major employer and economic driver in the US. It ranks 10th in jobs with over 2 million workers, represents 1.3% of the nation’s gross domestic product, and generates $529 billion in economic activity $60 billion in state and federal tax revenues each year.4 But LTC has been slow to respond to the IOM2,3 retooling recommendations to recruit, retain, and incentivize a more highly educated nursing workforce, which is evidenced by the lowest nurse retention rates (49% for all categories)5 of any health care settings (e.g., hospital, clinic, etc). The RN role in LTC is important for a stable, positive nurse work environment and quality care. Certified nursing assistants provide the preponderance of direct patient care in LTC. However, it is the registered nurse (RN) that supervises, directs, delegates, mentors, trains, and evaluates the overall delivery of total nursing care. Indeed, the level of RN staffing in nursing homes e as opposed to licensed practice nurse staffing e is predictive of organizational quality care indicators including fewer total deficiencies, fewer quality of care deficiencies, fewer serious deficiencies, and fewer lawsuits.6e8 But LTC RNs do not remain in their positions for very long. There have been persistently high RN turnover (42.8%) and high RN vacancy rates (10%)5 in LTC and these factors have contributed to lingering image problems, stressful work environments, lowered job satisfaction, and even concerns for patient safety and quality care.9,10 Together, these poor RN workforce indicators have been an economic drain for the industry in terms of the associated costs of RN replacement. The most recent estimates for RN turnover are calculated at $82,006e$88,032 per nurse,11 which includes costs for pre-hire (i.e., recruitment, vacancy coverage, hiring processes) and post-hire (orientation/training, new-hire productivity, pre-turnover productivity, termination).12,13 There is also some concern that most RNs e especially in LTC e may not be fully prepared through their educational curricula to care for the gerontological patient, which may also contribute to the LTC issues of high RN turnover and low retention. Only about 50% of baccalaureate degree nursing programs include a dedicated course for gerontological nursing care in their curricula.14e16 The preponderance of LTC RNs e nearly three-fourths e are associate degree graduates who are even less likely to have had specific gerontological nursing coursework in their 2-year program e making the issue of an underprepared geriatric RN workforce in LTC even more compelling.17 Studies conducted in acute care settings show that patient outcomes improve when older adults are cared for by RNs who have gerontological education.18e22 The measure of nursing
excellence for RNs is national board certification in a clinical specialty, which has been shown to improve inpatient mortality and failure to rescue.23 In addition, job satisfaction increases for LTC RNs who have participated in continuing education.24 The American Nurses Credentialing Center (ANCC) offers a clinical certification, Gerontological Nursing, for RNs who care for older adult patients.25 Earning this certification confers the credentials of “RNBC.” Nationally only 1% of RNs are board certified in this clinical specialty,14 which may be linked to the fact that clinical specialty certification is not easily attained. For example, RNs seeking Gerontological Nursing certification must demonstrate the equivalent of 2 years full-time practice with at least 2000 h in gerontological nursing within the last 3 years, and 30 h of continuing education in gerontological nursing within the last 3 years. The certification exam fees are $395 and it is a rigorous test with an 85% national pass rate.26 In addition, the exam is administered at an official test site, which may be challenging for RNs living in rural communities. Another barrier has been the lack of incentives for LTC RNs. Without employer support (i.e., paid time, assistance with course or exam fees, flexible work schedules) or workplace incentives (i.e., increased pay, job responsibility, or promotion) few LTC RNs have been motivated to pursue clinical certification as a means of enhancing competency. In 2009, an academic medical center collaborated with 13 Midwestern businesses representing 60 long-term care facilities on a match grant. The academic/community partnership used a community-based participatory research (CBPR) approach to develop, implement, evaluate and disseminate the project, whose primary goal was to retool the LTC RN workforce through national certification education in Gerontological Nursing. A corollary goal was to improve LTC RNs’ technological competency for life-long learning skills so that once certified, these LTC RNs would be capable of maintaining their credentials through computer-based research, evidence based practices, and on-line continuing education. Yet another goal was to develop a distance education course for LTC RNs that was a satisfactory learning model. Before enrolling in the Gerontological Nursing course, RN participants and their employers signed contracts in which RNs agreed to complete weekly assignments in a timely manner, preregister for the national certification examination, share costs of the exam fee, and commit to taking the national certification exam. Employers agreed to share in at least 50% of the certification exam fees. The hypothesis for this CBPR project was that Gerontological Nursing certification education would improve RN clinical competency, job satisfaction, intent to turnover, and empowerment. The associated research questions were: (1) Does certification education change participants’ empowerment, job satisfaction, and clinical competency over time?; (2) Are changes in RN intent to turnover associated with changes in RN empowerment, job satisfaction, and competency over time?; (3) Do RN empowerment and competency affect job satisfaction?; and (4) Do RN supervisors assess improved clinical competency among participants? Two corollary questions for this CBPR project were to determine if RN participation in distance education was a satisfactory experience and improved RN computer technology skills. The University of Nebraska Medical Center Institutional Review Board approved the study. The authors utilized a mixed methods approach using qualitative and qualitative methods to conduct a process and outcomes evaluation of the project. The data set provided responses to multiitem surveys from which scales were computed describing the study’s key outcome measures for empowerment, job satisfaction, intent to turnover, and competency among RN participants who had completed the project’s educational course.
M.E. Cramer et al. / Geriatric Nursing xx (2014) 1e6 Table 1 Gerontology nursing course participation, completion, and certification.
Table 2 Instrument coefficient alphas for study sample responses.
Cohort # Invited # Enrolled # Completed (%) # Dropped out (%) # Passed (%) Gero 1 24 Gero 2 28 Gero 3 25 Gero 4 23 Total 100
24 28 25 23 100
20 22 19 22 83
(83.3) (78.6) (76.0) (95.7) (83.0)
4 6 6 1 17
(16.7) (21.4) (24.0) (4.3) (17.0)
20 22 16 11 69
(100.0) (100.0) (94.1) (100.0) (98.5)
Methods Sample The unit of study was RNs employed in LTC facilities that had completed the project’s educational course. A list of RNs (N ¼ 100) was obtained and selection criteria included current employment in one of 63 LTC facilities owned by the project’s five LTC business partners and RN interest in participation. One hundred LTC RNs enrolled in the educational course that was taught twice per year. The overall attrition rate during the two-year project was 16.0% (16 out of 100) (see Table 1). The reasons that RNs left the course before completion included employment resignation (n ¼ 5), personal or non-specified issues (n ¼ 5), and not enough time (n ¼ 6). The final sample that completed the course was N ¼ 84 RNs. Measures The key outcomes evaluated included empowerment, job satisfaction, intent to turnover, clinical competency, technological skills, and course satisfaction. We used a retrospective pretest methodology to administer surveys at a single point in time after program completion. Participants rated the level of change that occurred because of their participation (e.g., “Before I participated in this course, my level of knowledge was. After participating in this course, my level of knowledge is..). Evidence shows that the retrospective pretest methodology produces more accurate selfassessments of program outcomes than the traditional pretest/ posttest, which is administered at two separate points in time and often results participants underestimating the program’s impact on their changed knowledge, attitudes, and practices or behavior.26 Clinical competency was measured using the 31-item Hartford Geriatric Competency Tool,27 which evaluates eight domains: communication, physiological and psychological age changes, pain, skin integrity, functional status, restraints, elder abuse, and discharge. Our participants self-rated their level of clinical competency before and after course participation. We also sent the instrument to the participant’s supervisor and asked him/her to rate the participant’s clinical competency before and after program participation. Job satisfaction was measured with a 5-item instrument, General Job Satisfaction Scale, which was derived from the theoretical and conceptual work that resulted in the Job Diagnostic Survey.28,29 The measure for RN turnover, Intent to Turnover Scale, was a 3-item instrument from Cammann, Fichman, Jenkins, and Klesh.30 We measured empowerment using the 12-item Psychological Empowerment Instrument31 that focuses on RN perceptions of formal and informal power, participation in decision-making, control over practice, leadership within the health facility, and recognition of expertise by others. To measure RN technological competency and course satisfaction we developed two instruments specifically for our project. The 6-item instrument, Technology Skills Survey, assessed participant ability to perform specific technological tasks for on-line learning (e.g., computer-based web searches, literature searches, etc) before and after course participation using a 5-level ordinal response set
3
Psychological empowermenta Job satisfactionb Intent to turnoverc
Before
After
0.87 0.67 0.11
0.89 0.75 0.07
Before
After
0.76 (remove #3)
0.65 (remove #3)
a The 12 items were reverse coded. Four subscales were computed from three items each with “empowerment” being the average of the four subscales. b Job satisfaction had 5 items and there was reverse coding for items 1, 3, and 4. c Intent to turnover was computed from 3 survey items with no reverse coding.
from strongly agree to strongly disagree. Three content experts reviewed the instrument for face validity but no reliability or validity testing was done. The 5-item Satisfaction Survey included one item for overall satisfaction and four open-ended items: (a) how participants intended to use the information gained, (b) what changes participants expected to see in their LTC facility because of their certification, (c) what suggestions participants had for course improvement, and (d) what participants identified as the best experiences in the course. Three nursing faculty reviewed the instrument for face validity but no reliability or validity testing was done. Procedures We mailed surveys to N ¼ 84 RNs approximately 4e6 weeks after they had completed the educational course. To maximize our response rates, we used the Dillman-tailored design method that requires up to four contacts.32 First, we sent an advance email to our participants explaining the purpose of our study and the importance of completing the surveys. Approximately one week later we sent packets containing the cover letter, the instruments and a self-addressed envelopes. An email reminder was sent to RN participants five days later to encourage them to complete and return the surveys. Non-respondents received a second packet with the cover letter, surveys and self-addressed envelopes approximately two weeks after the email reminder. The final response rate was 72.6% (61 out of 84). Analyses We computed the instrument coefficient alphas for each of the scales for both pre- and post- course completion based on our study sample respondents. A composite score for Psychological Empowerment scale (see Table 2) was computed from the average of the instrument’s four subscales. The Job Satisfaction scale was reverse coded for 3 of the 5 items and a composite score computed for an average (see Table 2). The intent to turnover alphas were greatly improved when the third item of the scale was removed; thus, the score was computed from an average of 2 of the 3 items (see Table 2). It might be conjectured that the third item of the scale that was removed (“How likely is it that you could find a job with another employer with about the same pay and benefits you have now?”) may reflect more on the profession of nursing itself. In other words, it may not have the same assumed relationship to the first two variables that it does for the other professions for which this scale was developed. Improved results for the Hartford Competency scale were achieved with a weighted average of a subset of the subscales for physiological and psychological, functional status, restraints, and discharge planning. Thus, the overall competency measure was computed on only these 4 subscales (see Table 3). We computed measures at two time points labeled as pre- and post-participation. To examine research questions 1, 2, and 3 there were two responses collected from each participant. For the first
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Table 3 Individual alphas for seven subscales of Hartford Competency based on sample responses.
Table 5 Change in intent to turnover as a function of empowerment, job dissatisfaction, and competency.
Scale
No. of items
Before
After
Scale
DF
Estimate
Standard error
t-value
p-value
Communication Physiological & psychological age changesa Pain Skin integrity Functional statusa Restraintsa Elder abuse Discharge planninga
4 7 3 2 8 3 1 3
0.61 0.76 0.80 0.31 0.85 0.91 e 0.23
0.025 0.60 0.04 0.03 0.39 0.91 e 0.67
Empowerment Job dissatisfaction Competency Time
1 1 1 1
0.161 0.429 0.137 0.23
0.111 0.034 0.314 0.119
1.45 12.6 0.44 1.92
0.15
