Identifying the core competencies of backup nurses in the acute care hospital through a modified Delphi process^†

This study used a modified Delphi process where an initial role description and a comprehensive list of potential competencies were established following a framework of TNA, literature review, and focus groups. These were presented to an expert panel for consideration in two rounds.

2.1.1

Theoretical framework

The framework of TNA guided this study.³⁰ We set up a research framework for TNA as shown in Figure 1: The first quadrant is a macro-instrumental requirement, such as basic nursing skills, technology skills, drug knowledge, etc. These skills will be dramatically improved after short-term training and are fundamental requirements for the backup nurses. The second quadrant is a macro-expression requirement, such as nurse-patient communication skills, teamwork, nurse stress adjustment, etc., and they will not show their effects immediately, but will help to improve the backup nurse team gradually. The third quadrant is a micro-expressive requirement, such as research training, nursing management and policy awareness. The fourth quadrant is a micro-instrumental requirement that provides nursing training only for certain special diseases.

Figure 1

2.1.2

Initial identification of core competencies of backup nurses

Initially, 47 items were selected and circulated to experts in the first round of the modified Delphi questionnaire to identify the core competencies of backup nurses. There are 5 categories and 15 secondary entries (Figure 2).

Figure 2

A purposive sampling was used to recruit a panel of experts. An expert was defined as a registered clinician and nurse who is working in Emergency Room (ER) or Intensive Care Unit (ICU), nursing manager who is responsible for policy making, and medical educator with >15 years working experiences, at mean while each expert must be proficient in the theoretical knowledge of this profession and has rich practical experience. It is a heterogeneous panel to make sure the study benefitted from the diversity of participants’ experiences and opinions. The survey rounds were conducted between December 2017 and March 2018. If a participant had not completed the round at this point, without advance notification, they were excluded from further rounds of the process.

Each indicator consisted of a series of competencies which the respondent could rate the importance of each research priority on a 5-point Likert scale (1 = low importance to 5 = high importance). In the first round, experts in the panel were also asked whether additional competencies were required. For the role description, each expert was asked whether they agreed with it or whether modifications were needed. At the same time, learning duration and evaluation method for each item were set. The Delphi process is an iterative process that uses repeated communication to refine expert opinion on the topic and move toward an acceptable level of agreement.

The results were statistically analyzed using SPSS 21.0 software and Excel 2016. Enumeration data is expressed in frequency and percentage, measurement data is expressed in mean and standard deviation (SD), and the degree of coordination of expert opinions is described by the coefficient of variation. P < 0.05 means the difference is statistically significant. In the first round of the study, the items were selected to ensure the importance assignment mean 3.80 and the coefficient of variation 0.30. The second round of item screening is to provide the importance assignment mean 4.00 and the coefficient of variation 0.20 as the standard. In addition, the items were screened in combination with expert opinions.

The scope of backup nurse training, which the experts were asked to choose, included the target selection of backup nurses, department requiring training, employment period, and training period (Table 1).

Table 2 shows the core competencies of backup nurses for professional practice ability category. This category included core competencies for nursing theory (6 items) and clinical nursing skills (11 items). Because some items were eliminated during prior rounds, all items in the table should be considered reasonably important. The professional practice ability category is the largest one with 17 listed in it. The aim of the 17 items was to assure that the backup nurses can be involved in rescue missions in emergency situations.

In terms of duration of training, the theoretical training hours required approximately 45.39 h, with an average of 2.67 h/item. The practical training hours required approximately 62 h, with an average of 3.65 h/item. Regarding the choice of assessment methods, 10 items required operational evaluation (OE), 7 items needed theoretical evaluation (TE), 5 items required case evaluation (CE), and 1 item required SS.

Table 3 shows core competencies of backup nurses for critical thinking ability category. This category included 6 core competencies for foresight and judgment ability (two items), resilience (one item), comprehensive analytical ability (two items), and decision-making capacity (one item). The aim of these six items was to ensure that backup nurses can make correct assessments, judgments, implementations, and evaluations in emergencies.

In terms of duration of training, the theoretical training hours required approximately 15.19 h, with an average of 2.53 h/item. The practical training hours required approximately 22.4 h, with an average of 3.73 h/item.

In terms of the choice of evaluation methods, six items required CE, three items needed SS.

Table 4 shows core competencies of backup nurses for interpersonal skills category. This category included three core competencies for collaboration (two items) and self-adaptability (one item). The main focus of these three items is to ensure that backup nurses have a good communication and cooperation ability in teamwork, and can make reasonable self-emotional adjustments to the stress at work.

In terms of duration of training, the theoretical training hours required approximately 4.65 h, with an average of 1.55 h/item. The practical training hours required approximately 5.25 h, with an average of 1.75 h/item.

In terms of the choice of evaluation methods, one item required peer review (PR), one item needed SS, and one item desired self-evaluation (SE).

Through a modified Delphi process, a panel of experts reached consensus on 26 competencies and training scope for backup nurses in the acute care hospital.

In the view of accomplishing the sudden and urgent work status of backup nurses, the nature of this role is unstable, and full of uncertainty. It is easy to cause the work pressure on backup nurses. Therefore, the target selection of backup nurses favors younger nurses, and the nurses who have chosen to be employed for 1 year or 2 years is 35.29% and 29.41%, respectively. The recruitment period of nurses should not be too long, better <2 years (52.94%), otherwise it might lead to weak enthusiasm and high turnover rate.

In terms of the support of core competence training, experts believe that backup nurses need to focus on professional practice skills, critical thinking abilities, and interpersonal skills. The management ability categories and professional development categories from the initial questionnaires had a low support. Experts suggest that the main responsibilities of backup nurses are to temporarily supplement the lack of departmental nursing staff and do not require management ability as well as career development ability.

Regarding duration of training, the theoretical training hours required approximately 65.23 h, and the practical training hours required around 89.65 h. It means backup nurses must complete at least 154.88 h of training to complete all 26 core competencies.

To evaluate the effectiveness of backup nurses in core competence trainings the following evaluation methods should be used: 10 items required OE, 7 items required TE, 8 items required CE, 5 items required SS, 1 item required PR, and 1 item required SE. Notably, 9 core competencies needed two evaluation methods.

Professional practice ability category mainly assures that backup nurses can meet requirement of rescue missions in emergencies. It can provide knowledge and skills that guarantees nursing quality, improves the success rate of patient rescue, and also improves patient satisfaction. Experts believe that this is the top priority in the clinical practice due to the nature of the work of backup nurses. However, this category contains 17 core competencies, of which 6 items for nursing theory and 11 items for clinical nursing skills. This category requires 45.39 h of theoretical training and 62 h of practical training, respectively. Experts believed that the theory and CE method should be used in the nursing theory more often and the OE method should be used more in the clinical nursing skills.

Nurses require insight into their level of performance and need critical thinking skills to be able to provide evidence-based quality patient care.³¹ Research indicates that critical thinking skills are significantly correlated with nursing competence and clinically competent patient care.³² Critical thinking ability category in this study included 6 core competencies for foresight and judgment ability (two items), resilience (one item), comprehensive analytical ability (two items), and decision-making capacity (one item). The main focus of these six items is to ensure that backup nurses can make correct assessments, judgments, implementations, and evaluations in emergencies. This category required 15.19 h for theoretical training and 22.4 h for practical training respectively. Experts believed that the CE and SS method should be used in this category more often.

Backup nurses are often deployed to unfamiliar positions to deal with emergency situations. It is easy to cause poor work efficiency or medical disputes if the nurses do not have good interpersonal skills. Poor interpersonal skills negative experiences or emotions will also affect the nurse's work enthusiasm, method, and efficiency. Interpersonal skills category in this study included three core competencies for collaboration (two items), and self-adaptability (one item). The main focus of these three items was to ensure that backup nurses have a good communication and cooperation ability in teamwork and can quickly integrate into the work environment of the support department. And can make reasonable self-emotional adjustments to the stress at work. This category requires 4.65 h of theoretical training and 5.25 h of practical training, respectively. The evaluation method of interpersonal skills was more flexible, including PR, SE, and CE.

In China, no laws or regulations clearly define the role or scope of practice for the roles of backup nurses. Experts suggest that the training of backup nurses should be based on role competencies, focus on practical ability, and adapting to clinical needs. The training content includes the knowledge, skills, and abilities required for the role, and provides corresponding job training, including theoretical study, skill training, and clinical practice.

According to the investigation, different hospital nursing managers have different understandings and focuses on the core competencies required for backup nurses. The ultimate development direction of backup nurses is that general nurses or specialist nurses directly influence the training time, training cycle, and clinical use of backup nurses.

The findings of this study could be relevant to policymakers and nurse researchers working to codify backup nurses’ roles in China and offer insights on how to establish a scientific, feasible, and reasonable educational programs inclusive of local and customary norms. At the same time, the nursing manager should analyze the needs of the hospital for backup nurse roles on the actual requirements of that particular hospital, combine the core competence items of the backup nurses, and formulate a practical and feasible backup nurse training mode to improve the career path of the backup nurses.