Linda Nazarko MSc, PGDip, BSc, FRCN, RN, is senior lecturer at South Bank University and King’s College (visiting) and nurse consultant for older people at Richmond and Twickenham PCT.
Nazarko, L. (2007) Educational needs of nurses working in nursing home. www.nursingtimes.net …
VOL: 103, ISSUE: 7, PAGE NO: 32-33
Nazarko, L. (2007) Educational needs of nurses working in nursing home. www.nursingtimes.net
Background: This study investigates what difficulties nursing home nurses face in continuing their professional development.
Method: Two hundred nurses attending study days in the south of England completed questionnaires on their access to education, funding and educational needs. The questionnaire was almost identical to that in a study undertaken in 1996.
Results: Nursing homes employ more nurses from overseas than they did in 1996, and more employers provide funding for their nurses’ professional development. The average length of time in post has increased since 1996.
Conclusion: The nature of nursing home work has changed and residents require nurses with greater expertise than ever before. Employers are beginning to recognise this and to support staff in their educational needs. However, the study also shows that there is much to be done if staff are to receive the educational support they need.
The independent sector has always played a part in the provision of long-term care for older people but has been seen as somehow separate from the rest of healthcare provision (Hicks, 2001). However, in recent years nursing homes have increasingly been used as placements for pre-registration nursing students (Upex, 2000). Hicks (2001) argued that staff needed to be up to date in their own practice if they were to supervise students, while education also enables registered nurses to provide a better quality of care in nursing homes (Davies et al, 1999).
The nature of nursing home work has changed dramatically. Admission to these settings is driven not by social care needs nor by ill-defined physical frailty. It is directly associated with illness and associated disability - 79% of residents have mobility problems, 78% are cognitively impaired and 71% are incontinent. More than half of residents have dementia, stroke or other neurodegenerative conditions (Bowman et al, 2004). Nursing-home residents therefore require high levels of skilled care and most have some degree of behavioural disturbance (Rothera et al, 2003).
The study sample was a convenience sample of 200 nurses attending study days in the south of England aimed at nurses working in nursing homes. Attendants were invited to complete questionnaires consisting of both open and closed questions. Closed questions gained information such as their age, length of time in practice and in their current job, and CPD they had undertaken. Open questions asked for comments on how easy or difficult they found it to meet their educational needs and their perceptions of residents’ needs. Average response rates were around 75% of attendants at the study days.
The questionnaire was almost identical to the one used in a study undertaken 10 years earlier (Nazarko, 1996). The one difference was that nurses were asked for their job title, as it had been clear from the earlier research that this data would be useful for determining whether grade influenced access to employer support.
All respondents were female. Research has indicated that fewer than 5% of nurses working in care homes are male (Ball and Pike, 2005). The average age was 49 years, which is close to the average age of nurses in the NHS. In the original study nurses working in nursing home were on average five years older than those working in the NHS.
The age profile within nursing homes has changed. In the earlier study most nurses were in their 40s and 50s. Although more than two-thirds were aged 51 or more in 2006, the number in their 30s had increased (Fig 1).
In 1996, 63.4% of nurses had dependent children. In 2006 only 39% had dependents; 90% of dependants were children, 5% grandchildren and 5% parents. The proportion of nurses working part time was similar to that in the 1996 study; in 2006 40% of nurses worked part time compared with 37% in 1996.
Most respondents (95%) worked in independent-sector nursing homes; the remaining 5% worked in charitable homes. The number of beds in each home ranged from 17 to 172. The nurses also had more experience of working in nursing homes than in 1996, when 61% of respondents had been in post for two years or under. This might have reflected the period of rapid growth that nursing homes had been experiencing. In 2006, only 26% of nurses had been in post for under two years and these were predominantly younger and recruited from overseas (Fig 2).
The proportion of nurses from black or minority ethnic (BME) backgrounds has also increased. In 1996, 9% of nurses were from a BME background, generally describing their ethnic background as ‘West Indian’. In 2006, 42% were from a BME background. These were younger than non-BME nurses, as they were in their 30s and 40s, and came from Africa, the Philippines and India.
In 1996 only 5% of respondents had completed a course in care of older people but in 2006 20% had completed a course. This might reflect the fact that nurses working in care homes now find it easier to access such courses. In 1996 12% of respondents had a diploma in nursing and 2.4% had a degree in nursing. In 2006 10% of nurses had a diploma in nursing and 10% a degree in nursing.
Most nurses (61%) who attended courses in 1996 did so in their own time and paid their own fees and travel expenses. This has changed dramatically. In 2006 only 15% of nurses were in this position (Fig 3). There are two possible reasons for this change. The first is that national minimum standards require care home staff to have education and training (Department of Health, 2003). The second is that the nursing home sector is finally shedding the cottage industry attitudes that it once held. Employers are realising that good care is an essential part of their business strategy and that they cannot afford to offer poor care. Levels of employer support did not appear to be related to grade nor length of service.
In 1996 61% of nurses believed they faced difficulties in meeting their post-registration education practice (PREP) requirements because of difficulties organising childcare, finding suitable study days, getting time off work and funding. In 2006 only 10% of nurses said they faced these difficulties. These figures almost directly match the number of nurses who did not receive support from their employers in meeting their further educational needs.
Limitations of the study
This was a small study and all participants came from the south of England and were attending study days. As a result, the findings may not be applicable to nurses in other parts of the UK or nurses not attending study days. However findings in relation to age, ethnicity and education levels are similar to those in a much larger study of 9,000 nurses (Ball and Pike, 2005). Ethnicity levels identified within the study are applicable nationally.
Effects of the changing nature of nursing home care
Many nurses took the opportunity to comment in the open section of the questionnaire. The quotes below are representative of those received.
Nurses felt that they were caring for extremely frail people with complex nursing needs:
‘People are staying in the community a lot longer - when they come to us they have high levels of physical and mental frailty. The work is much [missing word] than it used to be. Our staffing levels have not increased to take account of the high level of need residents have.’
‘In the past we only had a few residents who were bed bound and required percutaneous gastrostomy (PEG) feeding and total care. Now increasing numbers of people are admitted with such needs.’
The level of specialist support that nurses could access to help them meet complex resident needs varied. This appeared to be related to the availability of nurse consultants and specialists in the community as well as the attitude of nurse consultants and specialists. Many nurses found it difficult to access specialist support and advice:
‘When one resident was admitted with very extensive and deep pressure sores we tried to get advice from the tissue viability nurse. The PCT didn’t employ a tissue viability specialist and the specialist at the hospital didn’t feel that advising nursing homes was part of her role. She relented when the GP threatened to have the resident admitted to hospital. It shouldn’t have to come to this. If we’re looking after people who would have once been cared for in hospitals then we need the support to do this.’
‘It can be difficult to obtain advice in a nursing home. Some NHS staff think that you are only asking because you’re not competent. That’s not the case - if a person was at home or in hospital they’d have access to specialists. Why should it be any different because the person is in a nursing home?’
Some nurses reported that they found it easy to access support and advice:
‘The PCT has a nurse consultant in older people and there are specialist nurses in wound care and continence. We can call for advice at any time and I’m sure this has prevented hospital admissions. We really feel part of the team.’
Increasing numbers of nursing home residents require palliative care and several nurses stated that had introduced the Liverpool Care Pathway for the dying patient (Marie Curie, 2006; Ellershaw and Wilkinson, 2003). They felt that this had improved the quality of care they provided:
‘The palliative care nurses have been wonderful. They have spent so much time with us and, now that we’ve introduced the Liverpool care pathway, symptoms are much better controlled and residents have a more peaceful and dignified death.’
Nurses felt that it was difficult to provide appropriate care to people with behavioural problems:
‘Large numbers of our residents have dementia now. We have no problems providing nursing care but it’s difficult to deal with behavioural problems. When we ask about behavioural problems prior to admission, staff in the local hospital often deny that these exist. We understand that a move can distress a person with dementia and [we] give the person time to settle in, but often behavioural problems persist. These can be difficult to manage and can distress residents who are physically frail but mentally alert.’
The nursing workforce is ageing and there are concerns that when nurses aged 50 and over retire there will be a severe shortage of registered nurses in the UK (Buchan and Seccombe, 2006). Nursing homes may well experience these demographic pressures earlier than the NHS. Since 1997 the number of beds in nursing homes has fallen (Fig 4), and a combination of the loss of these beds and the recruitment of nurses from overseas may have combined to prevent homes experiencing staff shortages in recent years. However, recruitment difficulties may soon begin to become apparent.
The UK-educated nurses in this survey were older on avarage than their counterparts working in the NHS and some of them entered nursing homes following a career in the NHS. Many of these nurses were already at retirement age and may choose to retire soon.
It appears that nursing homes have become increasingly dependent on internationally recruited nurses. In 2003 the number of nurses from overseas registering with the NMC exceeded the number of UK-trained nurses registering (Nazarko, 2004).
However, recent changes have dramatically reduced international recruitment to the UK. In September 2005 the NMC replaced the work-based ‘adaptation’ programme with a university-based overseas nursing programme. In addition, non-European nationals are required to take tests to demonstrate their proficiency in English.
By 2006 greater numbers of UK-trained nurses were registering with the NMC and the Home Office removed registered nurses at bands 5 and 6 from their list of shortage occupations. This meant that employers could not obtain work permits to enable them to employ nurses from outside Europe unless they could demonstrate that they had been unable to recruit a registered nurse from within the UK or the EU (Harrison, 2006). These changes mean that nursing homes can no longer rely on international recruitment to fill nursing posts.
Overseas nurses already practising in the UK may also be under threat. At present newly registered nurses are finding it difficult to obtain posts in the NHS due to a funding crisis in the service. Experienced registered nurses in acute and primary care trusts are also under threat of redundancy because of cost pressures. It is possible that the Home Office might decide that in view of the current employment situation that it will not renew the work permits of internationally recruited nurses when they expire.
Funding education in the future
Nurses working in nursing homes, like their NHS counterparts, need to be able to access different levels and types of education. They need specialist training modules in areas such as tissue viability, continence promotion, palliative care and rehabilitation, which can form part of diploma or degree courses. However, they also need short updates on theory and practice that are relevant to the needs of the people they care for. Nursing home nurses, like their colleagues in the NHS, need to be able to access specialist advice when they encounter complex nursing problems.
Hicks (2001) pointed out that, although the government funds the education of NHS staff, it does not fund that of nursing home staff. If external funding is not available and homes fund education, the cost of it must be passed on to residents. There is a danger that the best of homes will continue to fund education while the homes where education is most needed may choose not to support their nurses’ professional development above mandatory standards.
The consequence of providing higher levels of support in the community is that people are admitted to nursing homes with greater levels of physical and mental health needs than ever before. Fitzpatrick and Roberts (2004) stated that care home staff require effective education and training if they are to provide good-quality care. Although they made this statement in relation to care assistants, it applies equally to registered nurses.
This was a small study and more extensive research is required. This should focus on the characteristics of people cared for in nursing homes and the skills required by registered nurses in order to meet their needs.
Care home regulators should ensure that care homes meet mandatory requirements in relation to education, while PCTs should provide effective support to care home staff to enable them to meet the increasingly complex needs of their residents. Consultant nurses, assisted by specialist nurses and community matrons, could provide ongoing clinical and educational support. This is an effective use of resources and can reduce avoidable hospital admissions and improve quality of life for older people.
Funding should be made available to meet the educational needs of nursing home nurses. The government provides over £100m a year to support the training of social care staff in the statutory, private and voluntary sectors (Department of Health, 2006). Most of the funding (£87.8m) is allocated for developing NVQ qualifications and continuous professional development to enable care homes to meet national minimum standards. This funding should be split so that specific funds are available for NVQ training and specific amounts for the ongoing professional development of registered nurses. This funding should be ringfenced and the budget holder should be required to demonstrate that the funding has been used for the purpose allocated.
Care home admission is driven by health needs and disability associated with ill health (Bowman et al, 2004; Rothera et al, 2003). Staff in nursing and residential care homes need access to education and training on health issues, as well as clinical support to be available from nurses, allied health professionals and medical staff within the NHS. In view of this it might be more appropriate for PCTs to become the budget holders for ring-fenced educational funds. Many PCTs are separating their purchaser and provider functions so it is unclear how they might manage such funds in the future.
PCTs are also integrating with social services departments and developing joint education and training departments. Care home development funding could be held within such integrated units.
This small study indicates that the nature of nursing home work has changed and that nursing home residents require nurses with greater expertise than ever before. It indicates that employers are beginning to recognise this and to support staff in their educational needs. However, the study also shows that there is much to be done if staff are to receive the support they require to enable them to provide care that meets the needs of the sickest and most vulnerable older people in the UK.
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