The gerontological nurse specialist’s core competencies in China: A cross‐sectional study

Abstract Aim To describe the core competencies of gerontological nurse specialists and investigate the factors that contribute to the development of core competencies. Design A descriptive cross‐sectional study was conducted from August 2015–March 2016. Methods The descriptive study of gerontological nurse specialists’ core competencies used a self‐assessment instrument with three first‐level domains (attitude, skill and knowledge) and 9 s‐level dimensions. A total of 225 gerontological nurse specialists from ten provinces in China were selected by a convenience sampling method. Results The average core competency score of the gerontological nurse specialists was 3.78, in the middle level(3.30–4.17/5.00). Core competency was associated with gerontological nurse specialists’ age (p = .005), professional title (p = .017), hospital level (p = .006) and passion for geriatric nursing (p = .000). The average scores of attitude, skill and knowledge were 4.45, 4.02 and 4.18, respectively. All first‐level domains were related to age (p ≤ .021) and passion for geriatric nursing (p ≤ .008); knowledge and skill were associated with professional title (p ≤ .045) and attitude and skill were associated with hospital level (p ≤ .020).

Lee, 2016) than Advanced Practice Registered Nurses (APRNs) and Registered Nurses (RNs) when assessing the condition and taking care of older adults in hospitals (Dodge, 2010). Previous studies demonstrated that GNSs can effectively meet the health needs of older adults and improve their outcomes (Jiménez, María, Gómara, & Germán, Concha, 2015). Thus

| BACKG ROU N D
The core competencies were used as the standard for nursing administrators to evaluate nurses and determine their strengths and the areas in need of improvement (Conley, 2011), and they were the key to ensuring the provision of high-quality nursing services (Cutugno, 2015). Many studies on the competency of GNSs have been performed. These studies have identified the role of GNSs through qualitative methods (Jonsson, Hofoss, Kirkevold, & Foss, 2016), constructed a competence index (Cui & Feng, 2019;Huizenga, Finnema, & Roodbol, 2016;Liu et al., 2016), tested the reliability and validity of a self-made competence questionnaire (Kilpatrick et al., 2013) and assessed the current status of GNSs' emotional competence (Bahrami, Purfarzad, Keshvari, Rafiei, & Sivertsen, 2018). The subjects were recruited from long-term institutions or nursing homes (Huizenga et al., 2016;Jonsson et al., 2016) rather than from hospitals. A recent study in Israel described the professional competencies of gerontological nurse practitioners and found that they had a positive attitude about their clinical role but that their professional knowledge and skills could be improved (Yafa, Dorit, & Shoshana, 2016). However, few studies have described the core competencies of GNSs (Boscart, Mccleary, Huson, Sheiban, & Harvey, 2016), especially those working in hospitals.
However, 60% of medical-surgical patients were older adults and 46% were critical care patients, accounting for 50% of the patients in intensive care units in hospitals (Mezey, Stierle, Huba, & Esterson, 2007). Thus, the core competencies of GNSs in hospitals have a large impact on the health outcomes of older adults. In addition, the core competencies of GNSs also have an impact on the clinical skills and professional identity of nursing students (Hou, Zhu, & Zheng, 2011). Additionally, studies on the core competencies of GNSs also indicate the significance of clinical research, education and the career development of nurses in various countries (Chen & Wang, 2016). Therefore, this study describes the core competencies of GNSs working in Chinese hospitals from their own perspective, focusing on their attitude, skill and knowledge and investigated factors that can contribute to the development of core competencies.

| Design
This was a cross-sectional, descriptive study involving a self-assessment questionnaire. Convenience sampling was used to recruit participants who had completed the GNS training course of the Sichuan Provincial Nurses Association and still worked at the hospital. The

| Instrument
The "Gerontological nurse specialists' core competencies assess- The questionnaire used a 5-point response scale for the GNS to indicate the extent to which they agreed or disagreed with each core competency item. The response options were strongly agree, partly agree, agree, partly disagree and strongly disagree. Each core competency was categorized as low (<3.50), moderate (3.50-4.49) or high (≥4.50) based on the self-assessment score.

| Data collection
With the help of the Sichuan Provincial Nurses Association and the two training hospitals, we obtained the name, email addresses and hospital workplace of the GNSs. Then, two researchers on the team distributed questionnaires by hand to those who worked in Chengdu, the capital city of Sichuan Province and collected questionnaires on the same day. If a GNS worked in another city, we sent emails and a reminder email was sent to those who did not respond within two weeks. Ultimately, 79 questionnaires were collected by email.

| Data analysis
The basic demographic information (age, gender and education) and the professional characteristics of the GNSs (professional title, hospital level, working department and interest in older adult care) were described as percentages based on the number of responses. Medians and quartile ranges were used to describe the 69 core competencies of the GNSs, as the score of the core competencies was abnormally distributed. The relationships among the demographic information, professional characteristics and core competencies were examined by the Mann-Whitney U test or Kruskal-Wallis H test.

| Ethical consideration
This study was reviewed and orally approved by the ethics committee of West China Hospital of Sichuan University. Before the study, we distributed a letter of invitation and the questionnaire to GNSs to explain the study's purpose and the voluntary nature of participation. The GNSs were also informed that the return of the questionnaire would be interpreted as their consent to participate.

| Participants' characteristics
The study included 225 GNSs, 98.2% of whom were female, with a mean age of 29 years (lower quartile, 26; upper quartile, 33). In total, 61.8% of them were senior nurses and 83.5% worked at level three class A hospitals. Almost 80.0% of the GNSs were interested in their job. Table 1 presents details of the basic demographic information and the professional characteristics of the GNSs.

| The core competencies of the GNSs
The GNSs evaluated their core competencies as moderate (3.78) and the score for attitude (4.45) was better than that for knowledge (4.18) and skill (4.02).

| Attitude
The attitude of professional self-identity was high (4.67). GNSs understand the care needs of older adults and treat each person fairly and they do anything they can to promote the improvement of patients' quality of life. The GNSs love and are proud of their job and they are willing to influence the development of geriatric nursing.
The other attitude was learning enthusiasm, which was moderate (4.20). The GNSs lack enthusiasm for actively acquiring advanced knowledge and cooperating with relevant departments to provide personalized care and improve care quality. Professor of nursing: senior professional title, manage clinical staff and promote professional development.
Level two class B hospital: provides health services across several communities.
Level two class A hospital: provides health services across several communities and departments, medical staff, hospital management, medical technical and facilities are better than the level two class B hospital.
Level three class B hospital: provide medical and health services across regions, provinces and cities as well as across the country.
Level three class A hospital: The highest level hospital in China, which provides medical and health services across regions, provinces and cities as well as across the country and departments, medical staff, hospital management, medical techniques and facilities are better.
Geriatrics department: All patients are older adults. It can take care of all diseases of older adults and provide comprehensive treatment.
Interest in geriatric nursing: passion for geriatric nursing and taking responsibility for their work.

| Knowledge
The GNSs reported that they had middle-level knowledge (4.18) and their professional geriatric nursing knowledge (4.29), such as ageing, comprehensive syndromes of older adults, common chronic diseases, safety prevention, end-of-life care, professional nursing skills and community home care, was greater than their basic nursing knowledge (4.00), such as nursing ethics, health promotion, disease prevention and nursing research.

| Description and comparisons of GNSs' core competencies and characteristics
When the core competency scores were analysed according to the GNSs' independent variables of age, professional title, hospital level, working department and interest in geriatric nursing, statistically significant (p ≤ .05) differences were found except for the working department (p = .081). GNSs who were 40 years and older had statistically higher competency levels (p = .005), regardless of attitude, skill and knowledge, than those between 20-39 years old.
GNS professors had the highest geriatric nursing competency levels (p = .017), both in skill and knowledge. The attitude towards geriatric nursing did not differ by professional title (p = .088). GNSs working at level three class A hospitals had higher competency levels (p = .006) in terms of attitude and skill than other GNSs. In clinical work, GNSs who liked their job very much had the highest core competency levels (p = .000) in attitude, skill and knowledge.  (Beth, Ellen, Barba, Hu, & Efird, 2012;Li et al., 2017). Their scientific research and professional development skills were insufficient, similar to those of other types of nurses in China (Cao, Wang, Liang, & Chen, 2018;Li et al., 2017;Qi & &Wang, 2016). This may be because GNSs are mainly focused on direct patient care in clinical work like other nurses, so they have limited awareness of scientific research and the development of professional skills. Additionally, the skills of GNSs were not related to work department in this study, confirming the result of a previous study (Rawson, Bennett, & Ockerby, 2017). However, Wei, Niu and Ge described that the department had an impact on the core competencies of ICU nurses ( GNSs contribute to ward management, provide patient-centred care (Fukada, 2018) and have sufficient time and opportunity to focus on geriatric nursing and improve their professional skills.

| D ISCUSS I ON
GNSs' basic knowledge was better than their professional knowledge, and there was no difference in knowledge between GNSs working at different levels of hospitals. In China, older adults are more likely to choose high-level hospitals when they are sick (Shao, Tian, & Li, 2012); approximately half of the inpatients in high-level hospitals are older adults and the proportion is rising (Xu, Ma, Luo, & Wang, 2013). Therefore, GNSs at these hospitals have more opportunities to understand diseases of ageing (Rawson, 2017;Henni, Kirkevold, Antypas, & Foss, 2018;Koroknay, 2015). The results demonstrated that GNSs mainly focused on direct patient care (Huizenga et al., 2016) and that there was no professional role of GNSs in clinical work, such that they had limited awareness of the complete range of knowledge as a health advocate, scholar and professional. Meanwhile, GNSs lack the means and resources to obtain international and advanced professional information in clinical working environments (Huizenga et al., 2016). To improve professional knowledge, nursing managers need to not only use human resources appropriately but also provide more opportunities for continuing education ( (Selvig, Holaday, Purkiss, Hortsch, 2015) should be considered in future training. In this study, the core competencies of GNSs were related to age and professional title. Older nurses may understand patients and their care needs more deeply (Raquel, Guillermo, Montoya, García, & Hueso, 2019). A higher professional title indicates more professional training or more clinical experience, which is very important for improving nursing skills and knowledge (Esterson et al., 2013). Nursing managers can provide continuing education according to the age and professional title and the older GNSs and those with a higher professional title can be team leaders to share their clinical experience with other GNSs to promote core competence.

| Limitations
In this study, the convenience sampling of subjects limits the generalization of our results. Therefore, future studies are needed to validate the core competency scale with a larger sample size. In addition, the self-assessment may show falsely high competencies.

| Implications for nursing policy and practice
The findings can be used as a foundation to develop questionnaires to assess the core competencies of GNSs. The results of GNSs' core competence contribute to the GNS training course and nursing managers and nursing school teachers should adjust the training content and method and improve core competence according to the characteristics of GNSs. GNSs can also use the findings for self-cultivation in clinical practice or as motivation to participate in continuing education and other professional training to development their competency. Future research should explore interventions to improve the professional skills and knowledge of GNSs and verify whether they are effective by the assessment questionnaire.

| CON CLUS ION
GNSs play a very important role in geriatric nursing. This study showed that GNSs reported moderate levels of core competency and their communication skills, research skills and professional development skills need to be further developed. The core competency training and the clinical practice of GNSs should be taken into account to improve GNSs' competency in the future, according to GNSs' personal characteristics.

This work was supported by West China Hospital of Sichuan
University and Sichuan Provincial People's Hospital, which helped recruit participants. Finally, we thank all the participants.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.  Purfarzad, Z., Keshvari, M., Rafiei, M., & Sivertsen, N. (2018). Emotional competence: A core competence in gerontological