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How to Position, Attract and Retain Registered Nurses in Nursing Homes: A Qualitative, Explorative Study

Authors:

Ramona Backhaus ,

Maastricht University, NL
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Inge Jochem,

Zuyderland Care, NL
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Helga Reijnders-Paffen,

Zuyderland Care, NL
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Judith MM Meijers

Maastricht University; Zuyderland Care, NL
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Abstract

Context: In most countries, registered nurse retention and role development in nursing homes is a challenge.

Objective: To obtain insight into factors contributing to successful retention of registered nurses in nursing homes and into how to differentiate the role of vocationally trained registered nurses and baccalaureate-educated registered nurses.

Method: A qualitative, descriptive, explorative study. In June 2019, World Café was held, a method for hosting group dialogs, in which direct care professionals, managers, human resources employees, and teachers participated. A theme-based content analysis was used to analyze data.

Findings: Identified factors expected to contribute to retention were role clarity, role content, role model availability, room for professional development, learning on the job, a match between education and actual work, management and board-level support, adequate salaries, and a positive image of working in nursing homes. Vocationally trained registered nurses were considered to perform a key role resident care by serving as case managers. Baccalaureate-educated registered nurses were considered to focus on indirect care (e.g., coaching staff, stimulating evidence-based practices, implementing innovations).

Limitations: Due to the limited sample size and the qualitative, explorative nature of the study, findings can only be generalized with caution.

Implications: To refine registered nurse roles in nursing homes, it seems crucial to rethink the current roles and hierarchies. Even though management and human resources departments are considered responsible for contributing to role clarity and the creation of supportive practice environments, the registered nurses themselves are also expected to come up with their role.

How to Cite: Backhaus, R., Jochem, I., Reijnders-Paffen, H. and Meijers, J.M., 2021. How to Position, Attract and Retain Registered Nurses in Nursing Homes: A Qualitative, Explorative Study. Journal of Long-Term Care, (2021), pp.192–200. DOI: http://doi.org/10.31389/jltc.80
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  Published on 29 Jun 2021
 Accepted on 06 Jun 2021            Submitted on 21 Jan 2021

Introduction

In many countries, only the most frail and dependent older adults enter nursing homes. The adequacy and number of staff to deliver this complex high-quality care is a current major challenge. In general, most staffing practices in nursing homes focus on the quantity of staff, and little attention is paid to the specific tasks, skills, and competencies of different staff members (e.g., registered nurses (RNs), nurse assistants) (Backhaus et al., 2018a). The roles of RNs and other staff members working in the nursing homes are often viewed as interchangeable (Mueller et al., 2018) and have become blurred (Tuinman et al., 2016). Moreover, in most countries, RNs are trained in at least two different ways, at baccalaureate-level or intermediate vocational training. While the educational background of both types of RNs differs, their roles in daily practice often have become indistinguishable (van den Boogaard et al., 2019). In addition, although nursing home care is complex and requires a high degree of skill, the number of RNs working in nursing homes remains low (Backhaus et al., 2018b).

If the unique contribution of both types of RNs is not recognized within a nursing home organization, their numbers may decrease even further, as lower level staff are considered capable of fulfilling the same duties as higher earning RNs (Backhaus et al., 2018b; Phelan and McCormack, 2016). RNs not employed according to their level of competence might be hampered to grow in their role. Even if the value of RNs is recognized, nursing home organizations worldwide experience difficulties in recruiting and retaining RNs (Backhaus et al., 2018b; McGilton et al., 2016).

Differentiating between the role of baccalaureate-educated RNs (BRNs) and vocationally trained RNs is expected to positively contribute to the demand and complexity of care and to address nursing shortages (Terpstra et al., 2015; van den Boogaard et al., 2019). Paying more attention to the specific skills of both types of RNs may make it easier to employ them to their full scope of practice (McGilton et al., 2016). The role of the few RNs that currently work in nursing homes might be used more effectively, ensuring that the professional nursing care needs of residents are met (Mueller et al., 2018). Role clarity and a supportive practice environment (e.g., supportive managers, nurse participation in decisions) might contribute to attraction and retention of RNs in nursing homes (Backhaus et al., 2018b; Choi, Flynn and Aiken, 2012).

In the Netherlands, BRNs receive four years of training at a University of Applied Sciences, while vocationally trained RNs receive four years of training at a Vocational Education and Training (VET) college (Backhaus et al., 2018b). Based on their education, vocationally trained RNs (qualification level four according to the European qualification framework [EQF]) are prepared to work in more predictable care situations, based on standardized guidelines and routines, while BRNs (qualification level six according to EQF) are prepared to work in more unpredictable care situations and settings (van den Boogaard et al., 2019). In Dutch nursing home practice, this distinction is not that clear and roles differ between organizations (Backhaus et al., 2018b; Tuinman et al., 2016).

Without clear guidelines from professional organizations on how to employ the vocationally trained RNs or BRNs in nursing homes, individual organizations are left to independently determine and distinguish their roles (Backhaus et al., 2018b). Findings of a qualitative study (Backhaus et al., 2018b) have suggested that determining their roles requires board-level leadership, as board members are expected to have a vision on how to employ RNs within their nursing home and to actively facilitate their employment. A lack of vision on how to employ RNs probably means that their role is not distinguished from the roles of other team members, leading to difficulties in attracting and retaining RNs (Backhaus et al., 2018b). Universal job descriptions that clearly delineate their distinctive contribution in nursing homes are lacking (Mueller et al., 2018). To employ vocationally trained RNs and BRNs more effectively and to better retain them in the nursing home setting, more insight into their specific roles and factors that contribute to their retention is needed. The aim of this study is to obtain insight into how to retain and differentiate the roles of vocationally trained RNs and BRNs in nursing homes.

Design

In June 2019, a qualitative, descriptive, explorative study was conducted from a constructivist point of view in which data were collected by means of the World Café method (Brown, 2010). This is a method for hosting group dialogs around ‘questions that matter’ (Biondo et al., 2019; The World Café Community Foundation, 2019). In a welcoming ‘café’ environment, several small groups of four to five participants, at different tables, ponder and discuss questions of interest. After a specific time interval, all participants move between tables and form new subgroups where they discuss and build on previously mentioned ideas. At the end, all ideas and insights from the different subgroups and tables are presented plenary style and discussed through a large group conversation. (Biondo et al., 2019; The World Café Community Foundation, 2019).

Sample/Participants

Participants were employees from organizations participating in the Living Lab in Ageing and Long-Term Care. Purposive sampling was used to select participants who were interested in the topic and who were expected to provide particularly rich information (emic perspective) (Polit and Beck, 2008). To ensure that the collected data represented a range of perspectives, participants from different organizations and organizational levels were included. Those representing the long-term care organizations were direct care professionals (RNs or certified nurse assistants [CNAs]), nursing home managers, and human resources employees working in nursing homes of these organizations. Teachers educating RNs represented the Intermediate Vocational Training Institutes and the University of Applied Sciences. In an email sent to each organization participating within the Living Lab in Ageing and Long-Term Care, interested direct care professionals, nursing home managers, human resources employees, and teachers were invited to participate.

Data collection

The World Café was held in a meeting room of a nursing home participating in the Living Lab in Ageing and Long-Term Care. The session began with an introduction of the World Café method. After that, the participants were allocated into three different subgroups of four people with different vocational backgrounds (e.g., direct care professionals, managers, and teachers). The subgroups sat at different tables and discussed one of the three research questions. After each round, new groups were formed and participants moved to another table. After three consecutive rounds of 20–22 minutes, each participant had discussed and explored each question. The authors (RB, IJ, JM) acted as ‘table host.’ In each of the three rounds, they sat at the same table, introduced the specific research question to the participants, encouraged participation from all participants, and helped groups to keep on the specific topic.

At the beginning of each round, all participants were asked to write down their own ideas on a sticky note to make sure that the ideas of all participants will be heard. After that, each participant presented their own ideas within the subgroup and put the sticky notes on a placemat covering the tables. These first ideas led to lively discussions. Participants were encouraged to write down any upcoming ideas, comments, or questions on the placemat. (Biondo et al., 2019).

In rounds two and three, the table hosts summarized the previous dialog(s) to the new group, explained what was already mentioned on the placemat, and stimulated the group to build on these previously discussed ideas. Between rounds two and three, a short coffee break was held. At the end of the session, after the three discussion rounds, the three table hosts presented the main findings for the specific research question that was discussed at their table. These findings were then discussed through a large group conversation that lasted approximately 25 minutes. All table discussions, the plenary presentations of the table hosts, and the final group conversation were audio-taped. At the end of the session, a photograph from each placemat was taken.

Data analysis

The three plenary presentations given by the table hosts were transcribed verbatim by the primary author. In addition, the primary author listened to the audio tapes of each discussion round and analyzed the information written on the placemats, to check whether or not the table host had presented all themes that were discussed at the specific table. As this was the case, no information was added to the transcripts. For a member-check, the transcripts were sent to all participants (Thomas, 2017).

A theme-based content analysis was performed. The primary author divided the text of the transcripts into ‘meaning units,’ consisting of one or more sentence(s) or entire paragraphs of the transcript (Graneheim and Lundman, 2004). These meaning units were coded and themed into categories, to identify common themes within or between the responses to each question. Table 1 provides examples of quotes for all themes and subthemes.

Table 1

Examples of quotes documenting our findings.

Theme Subtheme Example quote(s)

Factors contributing to retention Role clarity ‘It needs to be clear ‘What is the role? How do we want to employ our RNs in the nursing home? How do roles differ?, so that it can be communicated clearly to everyone.’
Role content ‘For retention, it is important that the content of the role becomes clear: the CEO, the manager, human resources, they all might differ in how they interpret the role’
Role model availability ‘A role model should be present on the ward. That would be very helpful for students doing their internships, too: What does it look like to work in elderly care? What is the value of working in elderly care?’
Room for professional development ‘To develop further, RNs should get the space, ability, and support to develop their own role. They should also feel ownership towards this role.’
Learning on the job ‘Important is a work environment that stimulates and motivates you to learn, that provides opportunities for lifelong learning on the job.’
Match between education and practice ‘Student doing their internships should get the possibility to experience what working as an RN in nursing homes means: they should not only get familiar with the provision of basic care, but should be equipped to fulfill a (B)RN role during their internship.’
Management and board level support ‘Board level managers should clearly communicate: how do they see the role, what is expected from (B)RNs, how do I support this?’
‘The manager has a crucial role: often, there are conflicts between the BRN and the manager, while the manager should support the BRN in fulfilling her role.’
Adequacy of salaries ‘The salary can be a demotivating factor: if you see that other RNs, for example those working in hospitals, earn more money than you do.’
Image of working in the nursing home ‘If you say “I work in a hosital,” that has a better image than working in elderly care.’
‘Vlogging or blogging about our work might give a positive boost to the image.’
Differences between the role of RNs and BRNs Paying attention to all professionals who collaborate in the nursing home ‘It is hard to focus solely on the roles of RNs and BRNs. In the end, we all collaborate within the nursing homes, so it’s hard to leave out the role of certified nurse-assistants or master’s-educated RNs in this discussion.’
Difference RN and BRN ‘Vocationally-trained RN scan fulfill tasks related to coaching or “casemanagement” on a specific ward.’
‘The BRN has a helicopter view, seeking and looking for collaboration outside the ward: in research, policy, innovation, networks…’
Specialized RN ‘There is also room for RNs who have specialized roles: diabetes, wound care, these kind of themes…’
Roles and tasks of BRNs in nursing homes ‘It’s crucial that the BRN works also partly in direct care. To “see and feel” what it means to work in practice.’

After that, authors RB and JM discussed the data analysis until consensus was reached. In a last step, the categories were reviewed and discussed within the whole research group (RB, IJ, HRP, JM).

Rigor

To enhance the rigor of the study, different strategies were applied. Purposive sampling enabled us to compare the views of different participant groups (i.e., care professionals, managers, human resources employees, and teachers), illuminating differences between groups (Barbour, 2001). Person triangulation (i.e., collecting data from multiple participant groups to validate data by including multiple perspectives) and space triangulation (i.e., collecting data from professionals working in multiple sites to test for cross-site consistency) led to more complete insights into the research topics (Polit and Beck, 2008). Member-check was used for verification by participants. Cross checking of the coding process within the research team led to a refinement of the coding frame (Barbour, 2001).

Ethical considerations

According to the Dutch Medical Research Involving Human Subjects Act (WMO), approval from a medical ethics review committee was not necessary, as participants were not subjected to an intervention or procedures, and no rules of behaviors were imposed on them. All participants provided written informed consent. Before providing consent, they were informed about the procedure of the World Café method, that participation was voluntary, that the discussions would be audio-taped and transcribed, that their written notes would be also analyzed, that all findings would be treated strictly confidential, and that the findings would be published in a final report and/or a scientific article. Participants were able to withdraw at any time. All data were analyzed anonymously.

Findings

Twelve professionals participated in the World Café on behalf of four of the seven long-term care organizations (n = 9), one of the two intermediate vocational training institutes (n = 2) or the University of Applied Sciences (n = 1) participating in the Living Lab in Ageing and Long-Term Care. Table 2 provides insight into participants’ demographic and occupational characteristics.

Table 2

Participants’ characteristics (n = 12).


Demographic characteristics
Age in years (mean/range; n = 11) 44,6 (30–56)
Gender: Female 9
Occupational characteristics
Years of experience in current or comparable position (mean/range) 10,5 (1–25)
Direct care professionals (n): 5
    – Certified nurse assistant (n) 1
    – Vocationally trained registered nurse (n) 1
    – Baccalaureate-educated registered nurse (n) 3
Nursing home managers (n): 2
Human resources employees (n): 2
Teachers (n): 3
    – Vocational training institute (n) 2
    – University of applied sciences (n) 1

Factors contributing to the successful retention of RNs in nursing homes

Participants mentioned several factors that, in their eyes, contributed to the retention of vocationally trained RNs and BRNs in nursing homes (Figure 1).

Figure 1 

Factors expected to contribute to successful retention of registered nurses in nursing homes.

Role clarity

Role clarity was seen as a necessity for a successful retention. Having a clear vision of what the roles of RNs and other staff members are and how they differ from each other, as well as clearly communicating this vision within the organization was considered to contribute to role clarity. According to the respondents, role clarity would lead to more transparency and less resistance from non-RN staff members (e.g., CNAs), and would enable RNs to better fulfill their distinguishing roles.

Role content

It was considered desirable that generic job profiles for both types of RNs are developed and implemented, in which the specific role and tasks of RNs are described. Based on these, it would be possible to differentiate and evaluate the effects of their role fulfillment. When a generic job profile is available, it was still seen as important to pay attention to the development needs and individual preferences of the RN and the ward(s) on which the RN is working. At the same time, job profiles should not become too specific, in order to ensure that a RN could also work on another ward or another nursing home of the organization if needed. The educational programs of RNs should already pay attention to the role of RNs and differentiation of roles in nursing homes and should enable students to think about and learn what is expected from their role in nursing homes and how they can fulfill this role. The human resources employees stressed that, at this moment, the role of the RNs in nursing homes received little attention from their departments and assumed that a lack of clear RN roles was a major reason for RNs to leave.

According to the participants, nursing homes had started to ‘carve out’ all RN roles, as many RN tasks were taken over by others (e.g., ‘reserved procedures’ like catheterizations). RNs often see these reserved procedures as unique duty of their role. However, not all nursing home organizations allow their RNs to fulfil these duties, as some organizations have implemented a specialized team of RNs that will perform these procedures. Giving these tasks back to all RNs and giving RNs the possibility to regularly practice the reserved procedures to stay up-to-date was seen as a possibility to retain RNs in nursing homes. In addition, RNs should be more actively involved in nursing policy development within their organization.

Role model availability

Participants reported that, especially for young or less experienced RNs role model availability would be very helpful in finding their role and to develop their leadership as RN. Students doing their internships in the nursing homes might also benefit from RNs acting as role models.

Room for professional development

For successful retention, facilitating RNs’ professional development was considered a necessity. Nursing home organizations should invest in and facilitate lifelong learning and the development of career paths for RNs (e.g., completing a master’s level education to become a nurse practitioner). At the same time, RNs should get the space, ability, and support to develop their own role further and should feel ownership toward this role.

Learning on the job

Working in a stimulating environment that provides opportunities for lifelong learning on the job was considered a factor that contributed to the retention of RNs. According to participants, RNs were eager to learn on a daily basis and also enjoyed promoting lifelong learning to their colleagues. In addition, wards in which students were trained were also seen as an interesting work setting for RNs.

Match between education and practice

Teachers indicated that, especially for the vocationally trained RN, there is a mismatch between what RNs learn during their education and the actual work in practice. Clinical reasoning and searching for evidence in (scientific) literature were mentioned as examples. While in education, much attention is paid to both clinical reasoning and searching for evidence, students doing their internship in nursing homes often hear and see from staff members that it is not done in practice. When these young RNs start to work in a nursing home, they quickly adapt to the existing way of working. At the same time, educational training institutes receive as feedback that students are not adequately prepared. In our study, teachers saw it as their role to actively seek dialog with nursing home organizations. Joint appointments, in which professionals work within a care organization as well as an educational institute were seen as a best-practice to enable this dialog. A mismatch between education and practice was seen as a factor that led to RNs leaving their jobs.

Management and board level support

Management support (e.g., backing and supporting the RN, removing obstacles, giving trust, giving the freedom to be an intrapreneur within the organization) was considered to contribute to the retention of RNs, as managers could help RNs to take up their role. Especially with regard to BRNs, participants noticed that the relationship between RNs and managers was not always smooth, as some managers were not open to the BRN role. Buy-in from board members was seen as helpful to distinguish the role of RNs, for example by demonstrating that recruiting higher earning professionals can be an investment in the further development of the organization.

Adequacy of salaries

The salaries of RNs working in nursing homes was another mentioned factor. When developing the role of RNs, it should be evaluated whether or not the salary is adequate for the responsibilities that belong to the role. If responsibilities increase, the salary should increase as well. While most participants said that the choice to work in a nursing home should not be based on the salary, they recognized that some RNs stop working in nursing homes to start their own care service so they can earn more.

Image of working in the nursing home

All participants shared the opinion that to attract young RNs to work in nursing homes, the image of working in nursing homes has to improve. Participants stressed that, contrary to existing opinions from students and the general public, nursing homes can be an innovative setting to work in, as, for example, lots of technological and social innovations are implemented to improve resident care. The nursing home sector could showcase this much more, for example through blogging or vlogging. In addition, having role models and providing good supervision to students may also positively contribute to the image of working in nursing homes.

Differences between the role of vocationally trained RNs and BRNs in nursing homes

When discussing the differences between the role of the vocationally trained RNs and BRNs in nursing homes, participants stressed that it is difficult to focus solely on the roles of these two, without paying attention to the roles of CNAs or master’s-educated RNs, as all these professionals collaborate within the nursing home.

According to the participants, there are a lot of different professionals working in the nursing homes (e.g., RNs, CNAs, nurse assistants, nurse aides) and it is difficult to make changes in the current hierarchy of job levels. Ideally, a customer journey should be performed in which nursing home organizations assess what kind of care and services need to be provided to deliver good resident care. When the desirable care provision and services are defined, one could think about what type of staff should deliver these. Nowadays, many organizations try to ‘fit in’ the role of a vocationally trained RN or a BRN into the existing hierarchy of job levels, without changing existing roles. Staffing shortages make it difficult to critically assess and reorganize the current hierarchy, as organizations prefer to keep all current employees.

When thinking about the differences in roles, participants stressed that work experience is an important factor to consider. The educational background of a professional often says less than their work experience. As an example, they said that, often, experienced CNAs are better able to perform specific tasks than a vocationally trained RN with little or no experience.

Participants saw the vocationally trained RNs as those team members that, on one specific ward, coach and lead other team members in the direct care delivery, without fulfilling a hierarchical management role. In addition, vocationally trained RNs were expected to serve as case managers of the residents, being the primary contact person for residents and their family members. They were also considered responsible for promoting and stimulating evidence-based practices within their ward. Finally, participants stressed that these RNs should perform the so-called ‘reserved procedures’ (e.g., catheterizations).

In addition to having vocationally trained RNs that work on a specific ward, participants mentioned that it is also necessary to employ vocationally trained RNs with specialized roles. These RNs have, based on additional training and/or work experience, developed specific areas of expertise, e.g., diabetes or wound care. With their specific expertise, they can fulfill a consultation and educational role for different wards within the organization.

Roles and tasks of BRNs in nursing homes

Participants unanimously stressed that BRNs with different roles are needed in nursing homes. Like for the vocationally trained RNs, participants also mentioned specialized roles for the BRNs. Mentioned areas of expertise of these specialized BRNs were palliative care, wound care, resident behavior, or fall prevention. In addition, BRNs working in a generalist role, with a broad focus on improving quality of care were considered desirable (Table 3).

Table 3

Role of BRNs in nursing homes.


  • Staying involved in professional practice in order to stay familiar with what is going on in practice and to recognize how professional practice could be improved.
  • Signalizing challenges in the ward and being able to see the ‘bigger picture’ and collaborating within and outside the nursing home organization (e.g., with regard to research (literature), policy, innovation, national initiatives) with the goal of improving practice.
  • Stimulating (the uptake of) evidence-based practice.
  • Having knowledge about innovating and implementing change in a daily practice environment.
  • Focusing on the content of quality care without losing time in managerial tasks (e.g., developing work schedules, supervision of absenteeism); consider a ‘dual leadership role’ with ward managers in which BRNs focus on the content and ward managers on the managerial tasks; should not become a formal manager or have the ambition to become one.
  • Working on one or more wards within a nursing homes; when working on one ward, it is important to not solely work in direct resident care, but also focus on quality improvement and innovation; due to the scarcity of BRNs, consider giving BRNs the possibility to develop to work for more than one ward.
  • Being able to work according to and apply the seven roles identified in the CanMEDS theoretical framework (‘Nursing expert,’ ‘communicator,’ ‘collaborator,’ ‘manager,’ ‘health advocate,’ ‘scholar,’ ‘professional’) (Huizenga et al., 2016).
  • Participating in the nursing home organizations’ Nursing Advisory Council/Professional Advisory Council (by law, Dutch nursing home organizations are obliged to install an internal Nursing or Professional Advisory Council).
  • Being able to describe how and demonstrate that the tasks and responsibilities of BRNs differ from those of vocationally trained RNs.

Participants thought that the tasks of BRNs would not need to differ between psychogeriatric and somatic wards, while some stressed that the tasks of BRNs working in sub-acute or rehabilitation wards should differ. In their eyes, working as a BRN in sub-acute or rehabilitation wards would require them to assume a networker and collaborator role, as BRNs need to work much more closely together with home care organizations and other professional organizations.

Participants frequently discussed that the role of BRNs in home care is much clearer and that the roles of the different nursing care professionals (RNs, CNAs) working in home care are better distinguished from each other. In Dutch home care, BRNs fulfil a ‘district nurse’ role. Since 2015, these BRNs are, by law, responsible for the care needs assessments of home care clients. According to the participants, this formal responsibility had distinguished and strengthened their role. The possibilities for implementing a comparable role for BRNs in nursing homes were discussed, but the opinions of participants differed. Some participants thought that it could strengthen the role of BRNs in nursing homes, others considered the home care setting as too different or did not see the added value.

Discussion

This studied provided insight into the factors contributing to successful retention of both types of RNs in nursing homes and into how to differentiate the role of vocationally trained RNs and BRNs. Factors for successful retention identified were role clarity, role content, the availability of role models, facilitation of professional development, stimulating learning on the job, a match between RN education and their work in practice, management and board-level support, adequate salaries, and a positive image of working in nursing homes. Participants indicated that they found it difficult to discuss and define the differences between vocationally trained RNs and. Participants indicated that many factors (e.g., the work experience of RNs, the developed area of expertise [e.g., diabetes or wound care], the ward type) have an influence on the desirable roles RNs should fulfill.

Vocationally trained RNs were considered to perform a key role in direct resident care by serving as case managers of residents, being the first contact person for residents and staff and by performing the so-called ‘reserved procedures’ (e.g., catheterizations). In contrast, BRNs were considered to ideally focus more on indirect resident care (e.g., coaching staff, stimulating the uptake of evidence-based practices, implementing innovations). Although the educational programs to become a BRN in the Netherlands is nowadays based on the CanMEDS theoretical framework (Huizenga, Finnema and Roodbol, 2016), participants did not discuss the role of BRNs in terms of the CanMEDS framework in detail. In addition, it was considered desirable that vocationally trained RNs with specialized roles were employed within nursing home organizations where they can focus on their specific areas of expertise (e.g., wound care, palliative care, fall prevention). Participants stressed that vocationally trained RNs or BRNs should not fulfill a hierarchical management position within the nursing home.

Based on these findings, it can be concluded that for participants, although many insights were given, it was difficult to define clear roles and distinction between the roles of vocationally trained RNs and BRNs. This may demonstrate once more that there is no ‘gold standard’ for employing both types of RNs in nursing homes and that it is hard to define clear guidelines on how to employ and retain them (Backhaus et al., 2018b). Nevertheless, trying to employ RNs according to the broadly defined roles may be a relevant starting point, as currently few RNs are employed within the nursing homes and, if employed, their role often does not differ from that of other staff members (e.g., CNAs) (Tuinman et al., 2016). A recent systematic literature review has indicated that different factors may hamper the execution of role changes in nursing homes (van Stenis, van Wingerden and Kolkhuis Tanke, 2017). First, due to a shift from task-oriented to relation-oriented care approaches, the roles of all professionals working in nursing homes are developing further and change constantly over time. Therefore, as stressed by the participants in our study, solely focusing on the roles of RNs would be too limited. Second, it was concluded that to change roles in nursing homes, specific needs of professionals should be met. Among other things, and in line with our findings, van Stenis et al. (2017) identified that professionals working in nursing homes have a need for personal development, personal empowerment, and for demonstrating the professional expertise to enable role transitions and concluded that nursing home organizations should pay attention to the competence development of professionals. In our study, room for professional development and learning on the job were mentioned as important retention factors. At the same time, participants stressed that organizations could invest more in competence development, e.g. giving opportunities for staying up-to-date and regularly practicing the so-called reserved procedures. Ideally, RNs should have a voice in their own learning trajectory (van Stenis et al., 2017). In addition, van Stenis et al. (2017) found that in nursing home organizations, direct care professionals are often not involved in decision-making processes (e.g., with regard to organizational change), leading to a lack of empowerment and the feeling of having no ability to control and change their own role. Giving RNs a role in nursing policy development within the organization was seen as an important retention factor in our study. In addition, especially from BRNs, it was expected that they participate in the Nursing or Professional Advisory Council and are able to come up with their role (e.g., through describing how and demonstrating that their role differs from those of vocationally trained RNs). Coming up with their own role is important; as van Stenis et al. (2017) highlighted, nursing home organizations often do not recognize the potential of staff members and they interpret their jobs as encompassing fewer tasks than they actually entail (Huizenga et al., 2016). As a consequence, direct care professionals also do not fully recognize their role and do not act upon their full expertise (Huizenga et al., 2016; van Stenis et al., 2017). This lack of recognized and actually demonstrated expertise may be an explanation for why the roles of RNs in nursing homes have become blurred and why participants of our study had difficulties with concretizing the desired roles of both types of RNs.

Earlier research has demonstrated that a supportive practice environment was significantly associated with higher job satisfaction of RNs working in nursing homes (Choi et al., 2012). Factors that related to a supportive practice environment of RNs included being involved in facility affairs and decision-making, having a supportive manager, and having adequate resources (e.g., be adequately staffed to spend enough time with residents). In a study conducted in Dutch nursing homes, which measured the practice environment with the Essentials of Magnetism II © instrument, the researchers concluded that all measured elements of magnetism (e.g., having clinically competent peers, collaborative nurse-physician relationship, having clinical autonomy, receiving manager support, having control over nursing practice) could be considered relevant for the nursing home setting (de Brouwer et al., 2017). Our findings are in line with both studies, suggesting that in addition to focusing on the particular roles of RNs in nursing homes, it is also important to invest in the practice environment.

Limitations

Due to the limited sample size and the qualitative, explorative nature of the study, findings can only be generalized with caution. Even though the findings represent the specific views of a wide diversity of participants, the generated ideas may not be unique to these participants. In addition, purposive sampling may have led to selection bias. A strength of the World Café method is that it brings together a variety of different stakeholders who all represent different views. At the same time, based on this method, it is hard to assess whether or not data saturation has reached. However, in round three of the World Café, participants came up with few new ideas. By discussing the findings in a plenary session and conducting an additional member-check, we tried to give participants the opportunity to add more ideas. Although all participants were invited to report what they had written on their sticky notes, their participation during the following table discussions differed. Therefore, it might be the case that some participants did not mention all of their ideas that came up. How the table hosts fulfilled their role might have had an influence on the findings as well. As it was their task to lead the discussion, some ideas might have been discussed in more detail than others. Finally, most stakeholders worked in the nursing home setting, while a minority worked in the field of education.

Conclusions

This study showed that, even though it is considered desirable to employ different types of RNs in nursing homes, it continues to be a major challenge to define clear roles for vocationally trained RNs and BRNs working in nursing homes. At the same time, role clarity was seen as a major factor for successful RN retention. In line with earlier studies, this study showed that (board) management is expected to fulfil a central role in defining RN roles in nursing homes and that it seems desirable to invest in supportive practice environments (Backhaus et al., 2018b; Choi et al., 2012; de Brouwer et al., 2017). Besides (board) management, our findings suggest that human resources departments could contribute to role clarity and the creation of supportive practice environments. At the same time, our study showed that, even though management and human resources departments have a crucial role, the RNs themselves are also expected to come up with the further development of their own role. This was especially expected from BRNs. In addition, the participants representing educational programs stressed that in RN education, more attention could be paid to the role of RNs and the differentiation of roles in nursing homes, enabling students to think about and learn what is expected from their role in nursing homes and how they could fulfill this role. To further refine the roles of RNs in nursing homes, it seems crucial to rethink the current roles and hierarchies of all professionals working in the nursing home. A dialogic approach like the World Café method could be used by nursing home organizations to invite all stakeholders (direct care professionals, [board] management, human resources departments, educational programs) to concretize the different roles of RNs and other direct care professionals within their organization and to discuss the responsibilities of all stakeholders to improve staff retention. In future research, the influence of having a clear (board) vision on how to distinguish both RN roles and the roles of other staff members (the whole ‘skill mix’) within the nursing home and investing the practice environment (by considering all factors that, according to participants, could contribute to successful retention of RNs in nursing homes) on quality of resident care, RN retention and RN work satisfaction and wellbeing should be tested.

Competing Interests

The authors have no competing interests to declare.

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