Chapter 1 67 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 COMPETENCIES FOR NURSING PRACTICE IN A RURAL CRITICAL ACCESS HOSPITAL Elaine Hurme, PhD, RN 1 1 Chief Nursing Officer/Assistant Administrator, Pointe Coupee General Hospital, New Roads, LA, ehurme@pcgh.org Key Words: Competency, Rural Nursing, Rural Competency, Critical Access Hospital, Delphi, Generalist, Rural Nursing Research ABSTRACT Rural nurses are expected to demonstrate excellence in clinical decision making and function in a more independent, generalized fashion. Identifying those competencies specific to rural practice will provide a framework for nurses and help to ensure safe and quality patient care. This article identifies nursing competencies most associated with good nursing practice in Critical Access Hospitals. INTRODUCTION Rural nursing is considered a demanding as well as rewarding area of nursing practice. One major term that has emerged in the literature as descriptive of rural nursing practice is that the nurse must function as a generalist in the rural setting (Bigbee, 1993; Bushy, 2000; Bushy & Bushy, 2001; Bushy & Leipert, 2005; Crooks, 2004; Drury, 2005; Eldridge & Judkins, 2003; Huttlinger, Schaller-Ayers, Lawson, & Ayers, 2003; Kenny & Duckett, 2003; Kramer, 1996; LaSala, 2000; Lee & Winters, 2004; Long, Scharff, & Weinert, 1997; Rosenthal, 2005). In other words, nurses in rural settings must be cross-trained and possess the ability to perform competently in two or more clinical areas. The rural practice environment has many unique characteristics which govern how nurses practice differently from urban nurses (Eldridge & Judkins, 2003). Certain factors inherent in the rural population are a larger number of uninsured, higher rates of poverty, more participation in high risk behaviors such as cigarette smoking and excessive alcohol intake, and more obesity. Homicide rates are lower but deaths due to suicide and accidents are higher in rural areas. Rural nurses are often faced with working with older and outdated equipment, have to spend more time teaching due to illiteracy problems in the rural community, and have to deal with a lack of patient privacy and confidentiality in the small rural community. Rural hospitals also have fewer baccalaureate-prepared nurses and have a lower ratio of registered nurses to licensed practical nurses. Competency in Practice Benner (1984) wrote that expertise in nursing practice develops only after the nurse has tested and refined nursing hypotheses and principles in actual clinical practice settings. She conducted three studies which sought to determine how nurses attain skills and develop knowledge in the clinical area while progressing through the novice, advanced beginner, competent, proficient, and expert levels. Benner defined good nursing practice as skilled ethical practice coupled with scientifically based clinical judgment. Good clinical judgment and performance requiring a sound educational foundation combined with experiential learning were http://www.pcgh.org/ mailto:ehurme@pcgh.org 68 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 also strong premises of her competency building framework. She believed that clinical research is necessary to ensure best practices in nursing. The Origination of the Critical Access Hospital Critical Access Hospitals (CAH) became a reality through a federal program designed to address the financial problems of rural hospitals and improve access to health care for those living in rural areas (Bushy & Bushy, 2001). This federal initiative was entitled the Medicare Rural Hospital Flexibility Program created by the Balanced Budget Act of 1997. Critical Access Hospitals are cost-based reimbursed on a fee for service rate as opposed to Medicare DRG PPS reimbursed. Certain criteria Critical Access Hospitals must meet include limitation of the average length of patient stay to 96 hours, provision of 24 hour emergency services, and an inpatient census that can not exceed 25, excluding patients being cared for in outpatient surgery areas or in the emergency department. PROBLEM STATEMENT The primary purpose of this study was to identify nursing competencies most associated with good nursing practice in Critical Access Hospitals. The research objective was accomplished utilizing a Delphi panel of rural health nurse experts who were currently employed as Directors of Nursing in a Critical Access Hospital. STUDY DESIGN According to Linstone and Turoff (1975), the Delphi undergoes four distinct phases. First of all the participants contribute information to the issue or subject under question. Secondly, the group reaches agreement or consensus on the issue. If agreement is not reached then the third phase delineates and evaluates the reasons for the differences of opinion. Lastly, all of the information that has been previously gathered from the participants is analyzed and returned to the participants for consideration. According to these authors three rounds is considered sufficient to produce stability in the responses. Population and Sample The target population for this study consisted of registered nurses who hire, supervise, or manage nurses in Critical Access Hospitals. These registered nurses were subsequently referred to as “experts” in the rural hospital environment. A listing, including electronic mail addresses, of 27 potential panel members was obtained through the state Rural Health Association. The criteria for the selection of the panel members included the number of potential panel members received and the willingness of the potential panel member to participate in the three rounds of the Delphi study. Seven nurses agreed to participate in this research study. DATA COLLECTION AND ANALYSIS This Delphi study consisted of three rounds of consensus building. Each panelist received instructions along with the instrument for each round of the survey process via 69 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 electronic mail. The panelists were directed to address competencies among all nurses without focusing specifically on the new graduate or the experienced nurse. The initial Round One survey instrument consisted of two open-ended, probing questions regarding the identification of competencies unique to rural health nursing. The focus questions for this study were:  “What are the job skills/competencies needed by nurses employed in rural Critical Access Hospitals?”  “Please indicate whether the competency is considered: a) A clinical/technical skill b) A critical thinking skill c) A communication/interpersonal skill or d) A management/organizational skill?” The Round One instrument was divided into four competency headings which included Clinical/Technical Skill, Critical Thinking Skill, Communication/Interpersonal Skill, and Management/Organizational Skill. The seven panelists submitted a total of 149 items. The items were critiqued for repetitiveness and similar competencies were consolidated. Special caution was taken to ensure the uniqueness of the competencies that were submitted was preserved. The Round Two instrument consisted of items extracted from the panelist‟s original responses. The participants rated the job skills/competencies on the Round Two Instrument utilizing an anchored scale. A text box was provided for comments. This second group of responses was analyzed utilizing the descriptive statistics of group median, mean, and standard deviation. Competency items were ranked by descending mean scores from the highest importance to the lowest importance. In ranking the information, tied mean scores were ranked by ascending standard deviation scores. A smaller standard deviation indicated more agreement on a particular item. The data obtained from Round Two was used to develop the Round Three Instrument which completed this Delphi study. Each panelist was provided with the group median and their own unique score for each individual competency. An asterisk next to the competency indicated that the panelists needed to rank the importance of the competency utilizing the anchored scale. The lack of an asterisk next to the competency indicated group consensus had been achieved and no further action was needed by the panelists. The researcher received the Round Three Instrument results, assembled this information and proceeded with the summation process. A total of 102 unique competencies were consolidated from the original 149 competencies received during the first round. Consensus, ranging from 71% to 100%, was achieved on all 102 items at the completion of Round Three. Tables 1 through 4 provide a final listing of the identified competencies. DISCUSSION Rural nurse managers must ensure that a qualified nursing staff is available to meet the variety of health care needs of the rural community. In order to meet this demand, the manager must evaluate the individual nurse‟s ability to perform competently in the clinical setting. If a nurse demonstrates a deficiency in a certain area of practice, then the nurse manager must 70 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 address these deficiencies and devise a plan for competent performance by the nurse. Currently, the majority of research studies related to evidenced-based clinical nursing practice and competency assessment has taken place in the urban setting (Olade, 2004). Therefore, there exists a true need to further explore research topics particular to rural nursing. Rural nurse managers can utilize the information obtained from this research study which identifies rural nurse competencies to evaluate nursing performance. Furthermore, findings from this study can serve as a teaching/learning tool that nurse managers can incorporate into the development of facility educational programs. Finally, the most important reason for identifying competent nursing practice in the rural setting is to ensure the delivery of optimal patient care. Table 1 Importance of Clinical/Technical Competencies Needed by Critical Access Hospital Nurses Identified by Rural Nursing Experts Rank Clinical/Technical Competency Medª X b SD % d 1 Possesses the ability to perform a physical assessment on patients across the lifespan. 5 5.00 0 100 2 Knowledgeable of emergency procedures in all areas of the hospital, not only those that present to the Emergency Department. 5 5.00 0 100 3 Able to perform basic nursing procedures/treatments appropriate to the patient‟s diagnosis and age group. 5 5.00 0 100 4 Possesses the knowledge and ability to perform triage nursing assessments on individuals of all ages. 5 5.00 0 100 5 Possesses the knowledge and ability to perform emergency clinical nursing assessments on individuals of all ages. 5 5.00 0 100 6 Able to operate equipment utilized in patient care such as infusion pumps, suction apparatus, lifters, telemetry monitors, and defibrillators. 5 5.00 0 100 7 Knowledgeable of basic dysrhythmia recognition. 5 5.00 0 100 8 Knowledgeable in regards to intravenous therapy and the maintenance of peripheral and central venous catheters. (i.e. the delivery of IV drugs, drips, blood and blood products). 5 5.00 0 100 9 Performs nursing procedures based on the standards of care, hospital policies, and medical and nursing protocols. 5 4.86 .38 100 10 Possesses a working knowledge and the ability to perform/initiate respiratory therapy and phlebotomy measures so as not to delay patient care and treatment while on call services are being activated. 5 4.86 .38 100 71 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 11 Completes a nursing assessment within an established timeframe of admission to serve as a guide for the implementation of the patient‟s care plan. 5 4.71 .49 100 12 Knowledgeable of medications action and side effects. 5 4.57 .53 100 13 Applies the nursing diagnosis and institutes monitoring nursing interventions to improve patient outcomes. 5 4.57 .53 100 14 Is ACLS and PALS certified. 5 4.57 .53 100 15 Evaluates patient responses to nursing interventions and communicates responses through legible documentation and reporting. 5 4.57 .79 71 16 Knowledgeable of medication administration guidelines for all age groups. 4 4.49 .53 100 17 Implements the nursing process to provide quality care based on assessment, diagnosis, planning, intervention, and evaluation. 4 4.43 .53 100 18 Completes and continually updates the patient care plan according to the changing patient needs. 5 4.43 .79 71 19 Data collection related to the health status of the patient is systematic and continuous. 4 4.29 .49 100 20 Goals for nursing care are formulated and stated in terms of observable outcomes. 4 4.29 .49 100 21 Evaluation, reassessment, recording of priorities, new goal setting, and revision of the care plan is a continuous process. 4 4.29 .49 100 22 For emergency department purposes, is TNC certified. 4 4.29 .76 71 23 The patient‟s response is compared with observable outcomes, which are specified in the care plan goals. 4 4.14 .69 86 24 The nursing diagnosis is derived from the patient‟s health status data. 4 4.00 .82 71 25 Possesses fundamental computer technology skills in order to effectively utilize the Computerized Medical Record in the Emergency Department. 3 3.29 .76 100 Note: Mean ratings classified according to the following scale: 5.00 - 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 - 1.00 = no importance. a Median ratings indicated by Delphi panelists b Mean rating based on the following anchored scale: 5.00 - 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 - 1.00 = no importance. d Level of consensus=percentage of panelists within ± 1 of the median. 72 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 Table 2 Importance of Critical Thinking Competencies Needed by Critical Access Hospital Nurses Identified by Rural Nursing Experts Rank Critical Thinking Competency Medª X b SD % d 1 Possesses the ability to care for a highly varied group of patients with different diagnoses all located in one clinical area. 5 5.00 0 100 2 Possesses the ability to recognize any changes in a patient‟s condition and provide the most appropriate care at any given time. 5 5.00 0 100 3 Ensures the use of good judgment in clinical decision making. 5 5.00 0 100 4 Possesses the ability to recognize and respond to emergency situations occurring in all age groups. 5 5.00 0 100 5 Able to meet the needs of patients utilizing limited resources of the rural setting i.e. lack of transportation. 5 4.86 .38 100 6 Demonstrates initiative in providing patient emergent or non-emergent care within the scope of nursing practice. 5 4.86 .38 100 7 Must have a clear understanding of all disease processes and individualize these processes in planning patient care (i.e. wound care, fall prevention). 5 4.86 .38 100 8 Demonstrates the ability to work with minimum supervisory guidance in exercising independent judgment. 5 4.71 .49 100 9 Appropriately delegates and prioritizes patient care activities, and implements the nursing process to ensure that each patient is provided quality patient care. 5 4.57 .53 100 10 Able to successfully manage the patient‟s medication regimen. 5 4.57 .53 100 11 Utilizes broad pharmaceutical knowledge related to the prevention of drug interactions, and medication errors. 5 4.57 .53 100 12 Maintains clinical skills necessary to provide safe, effective nursing care without the availability of pharmacy or respiratory therapy 24 hours a day. 5 4.57 .53 100 13 Follows organizational policies/plans/procedures for safety, security, hazardous materials and waste, emergency preparedness, fire/life safety, medical equipment management, utility system management, and infection control. 5 4.57 .79 86 73 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 14 Identifies specific goals, objectives, and actions designed to meet the patient‟s needs. 4 4.43 .53 100 15 Executes specific patient care activities and/or interventions that will lead to accomplishing the goals set forth in the care plan. 4 4.43 .53 100 16 Applies cognitive, technical, and interpersonal skills in the overall coordination of patient care. 5 4.43 .79 86 17 Knowledgeable of Safety, Risk Management, Infection Control, and Emergency Preparedness procedures according to federal and state guidelines. 5 4.43 .79 86 18 Able to perform an assessment that collects in depth information about a patient‟s situation and functioning and then develop a plan of care based on this assessment. 4 4.29 .49 100 19 Analyzes problems and suggests appropriate solutions, taking action within the limits of authority. 4 4.29 .49 100 20 Able to successfully delegate lower level of care activities. 4 4.29 .76 100 21 Coordinates, organizes, secures, integrates, and modifies the resources necessary to accomplish the goals set forth in the care plan. 4 4.29 .76 86 22 Monitors the results of care provided in order to determine the care plan‟s effectiveness. 4 4.29 .76 86 23 Evaluates the care plan at appropriate intervals to determine the plan‟s effectiveness in reaching desired outcomes and goals. 4 4.14 .69 86 24 Knowledgeable regarding the discharge process of patients with special needs i.e. Home Health, Hospice, Nursing Home, patients requiring medical equipment at home, mental health issues, etc. 4 4.00 .82 100 Note: Mean ratings classified according to the following scale: 5.00 - 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 - 1.00 = no importance. a Median ratings indicated by Delphi panelists b Mean rating based on the following anchored scale: 5.00 - 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 - 1.00 = no importance. d Level of consensus=percentage of panelists within ± 1 of the median. 74 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 Table 3 Importance of Communication/Interpersonal Competencies Needed by Critical Access Hospital Nurses Identified by Rural Nursing Experts Rank Communication/Interpersonal Competency Medª X b SD % d 1 Possesses the ability to communicate clearly and effectively with other members of the hospital team. 5 5.00 0 100 2 Maintains high personal and professional standards. 5 5.00 0 100 3 Exhibits a professional image, good work ethics and serves as a positive role model to staff. 5 5.00 0 100 4 Gains the patient‟s confidence with professional considerate nursing care. 5 5.00 0 100 5 Refers to age specific competencies when teaching the patient and family. 5 5.00 0 100 6 Maintains confidentiality of patient, physician and employee information in accordance with standards established by the hospital in compliance with regulatory agency requirements i.e., HIPAA regulations. 5 5.00 0 100 7 Adheres to regulatory agency documentation requirements. 5 5.00 0 100 8 Demonstrates compassion and respect for the staff, patient and patient‟s family. 5 5.00 0 100 9 Clarifies unclear, illegible, or non-specific physician orders prior to implementation. 5 5.00 0 100 10 Knowledgeable of proper documentation guidelines 5 4.86 .38 100 11 Makes a positive first impression a personal priority, and is honest. 5 4.86 .38 100 12 Demonstrates positive interpersonal communication skills and projects a positive attitude. 5 4.86 .38 100 13 Accepts phone and verbal orders appropriately, transcribing and implementing orders correctly and in a timely manner. 5 4.86 .38 100 14 Strives for excellence, demonstrates high performance in all endeavors. 5 4.71 .49 100 15 Exhibits a customer-focused attitude toward others 5 4.71 .49 100 16 Fosters a team-focused, interdisciplinary approach to all patient care activities. 5 4.71 .49 100 17 Utilizes resources available to communicate with hearing/sight impaired individuals. 5 4.71 .49 100 75 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 18 Is a patient advocate regardless of the patient‟s age, culture, or religious background. 5 4.71 .49 100 19 Acts as a liaison between the patient and physician, and other hospital departments. 5 4.71 .49 100 20 Uses good listening skills, and communicates in an open and responsible, professional manner. 5 4.71 .49 100 21 Consistently demonstrates interest, caring and consideration in dealing with the patients, significant others, and co-workers. 5 4.71 .49 100 22 Possesses the ability to communicate effectively with nurses from other health care institutions that do not appreciate the role of the rural nurse 5 4.57 .53 100 23 Possesses the ability to verbally communicate in an unbiased manner with individuals from all socioeconomic and educational backgrounds. 4 4.43 .53 100 24 Demonstrates knowledge of Information Management requirements specific to the department and the hospital. 4 4.43 .53 100 25 Develops, initiates, and participates in the process of patient education, discharge instructions, and preparation of the patient/significant other for discharge or transfer. 4 4.43 .53 100 26 Cooperates with staff to achieve departmental goals and promote good employee relations, interdepartmental relations and public relations. 4 4.43 .53 100 27 Able to communicate with other health care providers in order to coordinate care after the hospital stay. 4 4.29 .49 100 Note: Mean ratings classified according to the following scale: 5.00 - 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 - 1.00 = no importance. a Median ratings indicated by Delphi panelists b Mean rating based on the following anchored scale: 5.00 - 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 - 1.00 = no importance. d Level of consensus=percentage of panelists within ± 1 of the median. 76 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 Table 4 Importance of Management/Organizational Competencies Needed by Critical Access Hospital Nurses Identified by Rural Nursing Experts Rank Management/Organizational Competencies Medª X b SD % d 1 Demonstrates flexibility and organizational skills in rapidly changing situations. 5 5.00 0 100 2 Possesses the ability to manage the care of patients being cared for by different physicians. 5 5.00 0 100 3 Possesses the ability to organize the patient care load utilizing the sometimes limited available staff. 5 5.00 0 100 4 Demonstrates proper time management skills in order to complete tasks in a timely manner. 5 5.00 0 100 5 Demonstrates the ability to function under pressure during a disaster maintaining a calm, controlled demeanor. 5 5.00 0 100 6 Makes clinical assignments based on the patient‟s needs and circumstances. 5 5.00 0 100 7 Possesses the ability to rapidly shift from one patient care area to another (i.e. Operating Room to Emergency Department). 5 5.00 0 100 8 Adapts easily to changes in work assignments and environment and is willing to assume additional responsibility and learn new procedures 5 5.00 0 100 9 Strives to promote a positive attitude with the team and accepts additional assignments willingly 5 4.86 .38 100 10 Possesses the ability to manage ancillary departmental problems after routine office hours. 5 4.71 .49 100 11 Knowledgeable of the facilities‟ organizational structure, including policies and procedures. 5 4.71 .49 100 12 Assists in the promotion and maintenance of high quality care through the analysis, review, and evaluation of clinical practice. 5 4.57 .53 100 13 Delegates needs/tasks appropriately 5 4.57 .53 100 14 Demonstrates the ability to multi-task. 5 4.57 .53 100 15 Demonstrates the ability and flexibility to recognize and accept changing conditions while continuing to perform to the best of one‟s ability. 5 4.43 .79 86 77 Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 16 Ensures a high quality of patient care through appropriate human and material resource allocation. 4 4.43 .53 100 17 Able to work independently of senior staff. 4 4.43 .53 100 18 Effectively utilizes certain key skills, including communication, critical thinking, negotiation, collaboration, as well as patient advocacy and empowerment. 4 4.29 .49 100 19 Ensures effective and efficient utilization of all hospital resources, human and material 4 4.29 .49 100 20 Demonstrates initiative by active participation in staff meetings, committees, and projects. 4 4.29 .49 100 21 Participates in the problem-solving process associated with Quality Improvement. 4 4.29 .49 100 22 Ensures that the services delivered to patients are medically necessary and are appropriate for the diagnosis, condition, or medical problem 4 4.29 .76 100 23 Coordinates the individual patients‟ needs within the context of all outside influences, including the health care delivery system, the community, and the payer source 4 4.14 .38 100 24 Functions as an integral member of the hospital‟s leadership team. 4 4.14 .38 100 25 Aware of professional and personal limitations and how to access assistance when needed. 4 4.14 .69 86 26 Considers under-utilization as well as over- utilization of resources in the evaluation of patient care. 4 3.86 .90 71 Note: Mean ratings classified according to the following scale: 5.00 - 4.50 = high importance; 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