Nurse competence in the interface between primary and tertiary healthcare services

Abstract Aims (a) To explore nurses’ self‐assessed competence and perceived need for more training in primary and tertiary healthcare services; and (b) to investigate the factors associated with these issues. Design Quantitative, cross‐sectional, descriptive. Methods The ProffNurseSAS, the Job Satisfaction Scale and socio‐demographics were used. A convenient sampling method was used to invite registered nurses from 23 primary (N = 104) and tertiary care wards (N = 26). Results Five significant differences in self‐assessed competence were identified, with none regarding the perceived need for more training between nurses working in primary versus tertiary health care. Nurses in primary health care had longer experience, and a larger proportion had continuing education. Nevertheless, this was not associated with either self‐assessed competence or the perceived need for more training. Years of experience, training or reported job satisfaction was not associated with the items on the ProffNurseSAS. Conclusion Findings indicate that nurses’ competence is same in primary and tertiary healthcare settings. Moreover, the findings of this research highlight areas that need further improvement and emphasis from both leaders and educational institutions when they attempt to ensure nurses’ competence.


| INTRODUC TI ON
Healthcare reforms and innovative policies have been introduced worldwide to meet the upcoming challenges due to an increased number of elderly people and people with chronic diseases (St. Sauer, 2015;Uijen & van de Lisdonk 2008). The healthcare services in Norway are divided into two levels. The state is responsible for tertiary healthcare services provided in specialist hospitals, outpatient services and emergency services, while the municipalities are responsible for primary health care, including general practice, home-based care and nursing homes. In Norway, the implementa- short-stay wards (Johannessen, Luras, & Steihaug, 2013;Lappegard & Hjortdahl, 2012;Romoren, Torjesen, & Landmark, 2011). Similar intermediate care wards have been implemented internationally to meet future healthcare challenges. They aim to ensure the integration of services and collaboration in and between primary and tertiary healthcare settings (Grimsmo & Magnussen, 2015;Smith et al., 2013). Intermediate care units have existed both nationally and internationally for several years in, for example, so-called general practitioner hospitals (GPHS) or cottage hospitals (Aaraas, 1998).
Nevertheless, the increasing focus on the decentralization, coordination and integration of services has led to more and more patients also receiving active medical treatment outside hospitals (Lillebo, Dyrstad, & Grimsmo, 2013;Swanson & Hagen, 2016). Healthcare services are exposed to efficiency demands, a focus on early discharge from pressured hospitals and a lack of financial resources (OECD, 2010(OECD, , 2013. These demands often lead to political initiatives that are not necessarily built on professionals' and/or patients' evaluations of what characterizes safe, quality healthcare services. The extensive development and complexity of healthcare services challenge the competence of healthcare workers (World Health Organization, 2010). International organizations have emphasized the importance of nurses' education and competence to ensure quality and patient safety in healthcare services (Institute of Medicine, 2003;International Council of Nurses, 2012). Competence has been described as a combination of knowledge, fitness, assessments and attitudes, but there is no consensus on a definition of "nursing competence" (Cowan, Norman, & Coopamah, 2005;Cowan, Wilson-Barnett, Norman, & Murrells, 2008). The World Health Organization describes "nurses' professional competence" as a framework of skills that reflects knowledge, attitudes, as well as psychosocial and psycho-motor elements (World Health Organization, 2009).
Nurses report that they need to increase their knowledge in, for example, pharmacology and age-related physiological changes.
Nevertheless, they report a lack of training and education in such areas (Simonsen, Daehlin, Johansson, & Farup, 2014;Simonsen, Johansson, Daehlin, Osvik, & Farup, 2011). The decentralization of specialist/tertiary healthcare services and the complexity of patient cases challenge the knowledge, training and competencies of nurses working in primary healthcare services. For example, there has been an increased use of medical-technical devices outside hospitals (Gautun & Syse, 2013). Studies from GPHS (Aaraas, 1998), intermediate care units (Garåsen, 2008) and community hospitals (Lappegard, 2016) indicate that the decentralization of specialist healthcare services does not necessarily have an impact on patient safety and quality, as measured by patient outcomes.
The importance of nurses' competence in ensuring patient safety has been confirmed in several studies (Finnbakk, Wangensteen, Skovdahl, & Fagerström, 2015;Kirwan, Matthews, & Scott, 2013;Needleman & Hassmiller, 2009), as well as its connections to healthcare quality (Naylor et al., 2013). Nevertheless, we could not identify studies that explore nurses' competence in the newly established primary healthcare wards.

| AIM
This study purported to explore and compare nurses' self-assessed competence, as well as their perceived need for more training and education in primary and tertiary healthcare services, respectively.
Moreover, the aim of this work was to explore factors associated with these issues, such as age, gender, continuing education, years of experience as a nurse, years of experience in primary health care, years of experience in hospitals, targeted training during the last two years and job satisfaction. An assessment of nurse competence might be used to promote professional development, to adjust nurses' competencies to public needs and to assess organizational performance (Hamström, Kankkunen, Suominen, & Meretoja, 2012).

| Design
This study had a cross-sectional, descriptive, quantitative design, using a questionnaire to explore nurses' competence in primary and tertiary health care. were invited from all the primary healthcare wards that treated patients who earlier were hospitalized: MAWs, units for patients ready for discharge, short-stay wards and rehabilitation and palliation wards (N = 20). Table 1 gives an overview of the included primary healthcare wards.

| Setting and participants
The wards are distributed in accordance with the establishment of the five MAWs in the county, in the five different municipalities containing the head city. In addition, nurses from three wards in the county hospital were invited to participate. These wards were selected due to treating patients considered similar to and representative of patients in primary health care, namely an infection ward (beds = 24), a geriatric ward (beds = 18) and an observation ward (beds = 22).
A convenient sampling method was used: all the nurses fulfilling the inclusion criteria in the selected wards were invited to participate. Consequently, we did not conduct sample size calculations.
Inclusion criteria were as follows: registered nurses with a minimum of one-year experience at their present job, nurses with a minimum of 50% clinical work with direct patient contact and nurses with sufficient Norwegian fluency to understand and respond to the questionnaire.

| Data collection
The questionnaire consisted of three different parts: Part 1: Demographics, which included information about gender, age, percentage of employment, educational background, experience as a nurse, experience with primary health care, experience with tertiary health care, type of ward and targeted training conducted during the past two years.
The development of the questionnaire was influenced by the validated questionnaire the Nurse Competence Scale (NCS) (Meretoja, Isoaho, & Leino-Kilpi, 2004). The ProffNurseSAS includes information regarding nurses' clinical practice, professional development, ethical decision-making, clinical leadership, cooperation and consultation and critical thinking. Nurses are asked to: (a) assess their own competence; (b) to evaluate their need for more training and education; and (c) to report whether this item was covered in their nursing educational programme (yes/no) related to each of the 50 questions in the questionnaire (Finnbakk et al., 2015). The questionnaire uses a 10-point numeric rating scale on the (a) and (b) items, respectively (1 = lack of competence/no need for further training or education, 10 = excellent competence/extensive need for further training or education).
The JSS builds on 10 aspects of working conditions: responsibility, variation in tasks, relationship to colleagues, physical environment, opportunity to use one's own abilities, summated job satisfaction, freedom to decide one's working methods, acknowledgement, income or wages and working hours. The scale is scored on a 7-point Likert scale, where 1 = very dissatisfied and 7 = very satisfied.
Informational meetings with nurses and leaders were conducted in all the wards (N = 23) before data collection, in addition to information about the study sent by email. The questionnaires were distributed on paper and collected in sealed boxes at each ward, during three weeks in March 2018.

| Statistical analysis
Frequencies were used to present characteristics of the study sam-

| Ethical considerations
Approval was sought and given by the Regional Committee for

| RE SULTS
A total of 245 nurses in primary healthcare wards fulfilled the inclu-

| Sample
Nurses' demographics (percentage of employment, years since graduation from nursing school, years of experience in primary and tertiary health care, respectively, continuing education after bachelor's degree in nursing, training for the past two years and training or education related to a specific patient case) are presented in Table 2.
Nurses in primary health care had significantly longer experience as a nurse and more years of experience from primary health care. A larger proportion of the nurses had continuing education after their bachelor's degree than tertiary care nurses (Table 2). Nurses' continuing education is presented in Table 3.
Training for specific patient cases was mainly conducted in primary healthcare nurses. This education included ventilator treatment (N = 16), care for patients with tracheostomies (N = 16), end-of-life treatment (N = 6) and peritoneal dialysis (N = 4). In tertiary health care, such specific training was related to the use of various medical-technical equipment.

| ProffNurseSAS
Comparative analyses, as assessed by the Mann-Whitney U test, showed only six significant differences in self-assessed competence on the 50 items of the ProffNurseSAS between nurses in primary and tertiary healthcare services. An overview of responses to each of the 50 items is presented in Table 4.
The items that showed significant differences were as follows: "I take patients' mental health needs (    Note. Mann-Whitney U test. Level of significance 0.05. Significant differences marked *. The scale for self-assessed competence ranges from 1 = bad to 10 = excellent. The scale for perceived need for more training ranges from 1 = no need to 10 = extensive need.

| Job satisfaction
Comparative analyses, as assessed by the Mann-Whitney U test, showed no significant differences in nurses' job satisfaction in primary and tertiary health care, respectively. An overview of nurses' scorings on the JSS is presented in Table 5. The mean value for primary healthcare nurses' job satisfaction was 5.9 (SD = 1.3, median = 6.0), and in tertiary healthcare nurses, it was 6.0 (SD = 1.1, median = 5.9).

| Multiple regression
Multiple regression analyses showed that the type of ward, percentage of employment and years of experience as a nurse/from primary health care/from tertiary health care, continuing education or reported job satisfaction were not associated with any of the items or the mean score of the ProffNurseSAS self-assessed competence or the perceived need for more training ( Table 6). The internal consistency, as measured by the Cronbach's alpha, of both the ProffNurseSAS questionnaire and the JSS questionnaire in this study was 0.9 (=excellent).

| D ISCUSS I ON
Findings show that nurses in primary health care had significantly more experience and a larger proportion had continuing education than nurses in tertiary health care. Five significant differences in   (Finnbakk, Skovdahl, & Blix, 2012). A stepdown in competence outside institutions has been shown in studies comparing staff in home-based care and staff in nursing homes (Hasson & Arnetz, 2008;Bing-Jonsson, Hofoss, Kirkevold, Bjørk, & Foss, 2016;Finnbakk et al., 2015). Our findings may indicate that municipalities have used the years from the implementation of the Coordination Reform (CR) in well. Haukelien et al. (2015) explored nurses' experiences with the implementation of the CR.
Then, nurses claimed that the municipalities could not build sufficient competence and a professional infrastructure to meet the increasing complexity and number of patients in primary health care. In contrast, the significant differences in self-assessed competence in our study indicated a higher self-assessed competence in primary healthcare nurses: primary healthcare nurses had significantly higher self-assessed competence on items such as considering patients' mental, spiritual, social and physical health needs when assessing and planning for the health and life situations of patients, as well as focusing on relatives' need for support and guidance. These items corroborate research on healthcare services with a patient-centred approach (e.g., Bowie et al., 2015;Kitson, Marshall, Bassett, & Zeitz, 2012). Studies have also reported that patients experience patient-centred care in the newly established municipal acute wards versus in hospitals (Leonardsen, Del Busso, Grøndahl, & Jelsness-Jørgensen, 2016, 2017. This may indicate that nurses in primary health care have higher competence in providing patient-centred healthcare services.
Nurses reported the lowest self-assessed competence for the item "I give health-promoting advice and recommendations to patients via telephone, email, or other digital solutions"; the highest perceived need for more training and/or education for the item "I have knowledge of the interactions of various types of medication and what side effects they may cause for the patients I am responsible for"; and the item "I give health promotion and illness preventive recommendations in accordance with national guidelines to patients." This is important information for a society that searches for digital solutions to increase the efficiency of healthcare services. Studies have shown that the overall level of nurse competence as perceived by nurses is high (Bing-Jonsson, Hofoss, et al., 2016;Istomina et al., 2011) and this is supported by our study. Nurses have assessed their competencies in managing situations and work roles as the highest and in teaching-coaching and ensuring quality as the lowest (Istomina et al., 2011). Moreover, nurses have reported insufficient competence in areas like nursing measures, advanced procedures and nursing documentation , as well as in psychiatric and palliative nursing and certain technical skills (Furåker, 2012). Consequently, the findings in our study both support and add to earlier research. In addition, our findings reveal areas where nurses' competence in both primary and tertiary health care could be improved. This knowledge is important when developing new healthcare services and in quality improvement initiatives.
Furthermore, areas that nurses reported as not covered by their nursing educational programmes were the "improvement of routines and systems," participation in quality and competence development and creative learning. This lack of education was also related to evaluations of differential diagnoses, interactions and side effects of medication and giving health-promoting advice to patients. Changes in the delivery of nursing have challenged nursing educators to seek innovative ways to ensure that their educational programmes produce competent practitioners. Schoneman, Simandl, Hansen, and Garrett (2013) , 2006). There were no significant differences in job satisfaction between nurses in primary (mean = 5.9) and tertiary health care (mean = 6.0). Job satisfaction was scored relatively high, and it was not associated with self-assessed competence or the perceived need for more training and education. This is in line with a study that found that nurse competence influences job satisfaction and nursing performance (Ha & Choi, 2010) and may indicate that there will be competent nurses to provide primary healthcare services also in the future.
Moreover, findings show that demographic factors, such as years of experience, continuing education or job satisfaction, were not associated with self-assessed competence or the perceived need for more training. This contradicts earlier studies, which identified nurse education, experience, professional development, independence, work satisfaction (Grönroos & Perälä, 2008;Istomina et al., 2011), professional group affiliation, workplace, age , gender (Hamström et al., 2012) and marital status (Kim & Kim, 2015) as predictors of nurses' self-reported competence. Of course, a larger sample size may have detected similar associations.
Results on nurses' self-assessed competence, their perceived need for more training (or lack thereof) and their reported job satisfaction indicate high quality and safety in both primary and tertiary healthcare services. In this study, we could not confirm the suggested differences in quality, safety and competence in policy documents and media between the two levels of health care or the worries about enough competence to meet future needs.

| Strengths and limitations
One limitation of this study is the lack of generalization of results due to the small sample size. A larger sample size may have given more significant differences. In some wards, the response rate was very high; in other wards, it was very low, and we cannot be sure that the sample is representative. In retrospect, we could have computed a power analysis and focused on including nurses accordingly, for example, by allowing the completion of questionnaires on professional development days. Moreover, we could have invited nurses from more hospital wards to better compare primary and tertiary health care. Nevertheless, the inclusion of so many wards representing both the central and rural parts of the county and both small and big units may strengthen the validity of our findings.
Nurses reported that the questionnaire was time-consuming to complete. A shorter questionnaire could have increased the number of responders: a review study and meta-analysis found that response rates were lower for longer questionnaires (Rolstad, Adler, & Ryd'en, 2011). Perhaps only nurses chose to participate who had high self-assessed competence and little need for further trainingor a positive attitude towards research and competence development. In addition, there is also a greater likelihood that those who felt the least competent refrained from taking part.
A limitation regarding the assumption that nurses in primary and tertiary health care have similar and sufficient competence is indicated in studies that indicate discrepancies between self-assessments and observed performances (Baxter & Norman, 2011;Lauder et al., 2008). Further studies need to be conducted to evaluate the association between self-assessed competence and actual knowledge and clinical skills.
The validity and reliability of this study is strengthened by the instruments used. The ProffNurseSAS, as well as the JSS, have been found to be valid and reliable (Andersen & Andersen, 2012;Finnbakk et al., 2015;Warr et al., 1979). The Cronbach's alpha was excellent in this study, which indicates proper internal consistency of the tools.

| CON CLUS I ON AND IMPLIC ATI ON S FOR CLINI C AL PR AC TICE
Findings show that nurses' self-assessed competence, perceived need for more training and job satisfaction were the same in primary and tertiary healthcare services. This indicates good quality, safe services for "the earlier hospital patients," regardless of decentralization. The main areas nurses expressed a need for further training were, for example, in using digital solutions in communication with patients, health assessment of patients and knowledge about medication interactions. Hence, results in this study may be useful in quality improvement initiatives across healthcare levels, institutions and wards, as well as to educational institutions.
Further studies on nurses' and other healthcare professionals' competence in a larger sample would be useful to support this study's findings and to add even more knowledge to this under-represented area of research. In addition, studies that support the link between healthcare personnel's competence and healthcare quality would be useful when planning educational and quality improvement initiatives.