As Canadians continue to age and become more dependent on assisted facilities, long-term care facilities (LTCF) are an increasingly important health care setting. In 2012, there were 1,360 nursing homes in Canada, not including Quebec (Canadian Institute for Health Information [CIHI], 2014). Registered nurses (RNs) are integral to ensure that high-quality care is delivered to the residents living in LTCF (Mueller, Bowers, Greenburger, Cortes, & Expert Panel on Aging, 2016) and with the aging demographics, there will continue to be a demand for RNs in those facilities. Residents living in LTCF are in need of continuous nursing care, as they are on average 85 years old and face multiple chronic conditions, including cognitive impairment, mobility challenges, and continence challenges (Canadian Institute for Health Information [CIHI], 2013).
Although most new RNs receive some leadership education during their nursing program, it is not specific to the knowledge and skills that LTCF nurses need to lead care for older adults in residential settings (O’Brien, Ringland, & Wilson, 2010). Furthermore, this lack of educational preparation on caring for gerontological residents may contribute to high turnover and low retention of RNs in LTCF (Cramer et al., Reference Cramer, High, Culross, Marks Conley, Nayar, Nguyen and Ojha2014). In addition, RNs are responsible for supervising other workers in LTCF, but few nursing programs prepare RNs to delegate tasks and responsibilities to others (Harvath et al., Reference Harvath, Swafford, Smith, Miller, Volpin, Sexson and Young2008). As a result, recently graduated RNs employed in LTCF present with several uncertainties, resulting in low job satisfaction and high turnover rates, which negatively impacts the quality of care for residents living in these environments (Chu, Wodchis, & McGilton, Reference Chu, Wodchis and McGilton2014). Most research on the topic has been aimed at understanding this experience at the RN level, but little is known about how others perceive the factors influencing the effectiveness of the new RN in LTCF.
Background
The role of the RN in LTCF is multifaceted. RNs conduct resident assessments and are involved in care planning, documentation, administering medications and treatments to residents, and supervising unregulated care providers, as well as communicating with residents and their families (The Canadian Nurse, 2011). This role entails mastery of a plethora of skills, competencies, and abilities in relation to complex and end-of-life care for residents and their families (Dellefield, Castle, McGilton, & Spilsbury, Reference Dellefield, Castle, McGilton and Spilsbury2015). It also entails the ability to lead and support a team of care providers, create a culture of person-centeredness, and guide quality improvements to meet all ministry regulations.
The RN role requires the nurse to have a strong capacity to lead, while practicing at a high level of competency and independence. Managers and team members expect RNs to be experts in resident assessment, care planning and provision, leaders in family engagement, and organization of any decision-making that leads to better resident outcomes (Anderson, Issel, & McDaniel, Reference Anderson, Issel and McDaniel2003). In addition, RNs are expected to be organizational leaders and mentors and to supervise teams of LTCF staff (McGilton, Bowers, McKenzie-Green, Boscart, & Brown, Reference McGilton, Bowers, McKenzie-Green, Boscart and Brown2009), including unregulated care providers such as personal support workers (PSW).
Unfortunately, the educational preparation for RNs does not always address the different facets of the RN role. Despite standardized expectations for all baccalaureate nursing programs (Canadian Association of Schools of Nursing, 2015), McCleary, Boscart, Donahue, and Harvey (Reference McCleary, Boscart, Donahue and Harvey2014) and Hirst, Lane, and Stares (Reference Hirst, Lane and Stares2012) found that gerontological content is insufficient in most BScN curriculum across the country. Furthermore, many new nursing graduates do not have the capabilities required to take on a leadership role, regardless of care setting, upon graduation (Bowers, Reference Bowers2011). It is therefore very difficult to attract and retain new RN graduates in LTCF. Coyne, Rands, Gurung, and Kellett (Reference Coyne, Rands, Gurung and Kellett2016) found that newly hired RNs in LTCF were unsure of the role expectations, did not always understand the responsibilities of their practice, and struggled to meet both the clinical and supervisory expectations of the RN role.
Given the aging demographics, the demand for RNs in LTCF will continue. However, the supervisory and clinical responsibilities that the role entails, coupled with the lack of specific LTCF educational preparation for new RNs, makes attracting and retaining new RNs in LTCF challenging. This study aimed to describe the different factors that influence the supervisory performance of new RNs in LTCF settings from the perspective of LTCF managers, policy advisors, and educators.
Conceptual Framework
This study utilized the socio-ecological model to frame the study (Bronfenbrenner, Reference Bronfenbrenner1977). Bronfenbrenner’s model discusses the continuous effect of the constantly changing environment on the individual. Bronfenbrenner states that processes are “affected by relations obtaining within and between these immediate settings, as well as the larger social contexts, both formal and informal, in which the settings are embedded” (p. 514). This model provides a fitting framework for examining the supervisory experience at different levels (micro, exo, and macro) and the factors that influence each level. For the purpose of this study, we examined the influences of the supervisory experience of new graduate RNs at three levels: (1) the individual level (microsystem); (2) the organizational level of the LTCF (exosystem); and (3) the structural factors or external forces beyond the control of the RN (macrosystem).
Methods
Design and Setting
This qualitative, descriptive study was part of a larger project that focused on factors influencing supervisory performance of RNs in LTCF. This particular study explored factors that contribute to supervisory performance of new RNs in LTCF.
Sample
Deans and directors of nursing programs, experts from professional nursing associations, policy advisors, and administrators were purposively chosen because of their expertise in supervisory performance of new RNs in LTCF. Five directors of care across five LTCF were also purposively selected on the basis of a larger study focused on examining supervisory performance of RNs in LTCF.
Data Collection
Three researchers, one research assistant (RA), and an RN pursuing a master’s degree in nursing (MSN) conducted telephone interviews with the policy-makers and deans and directors. The RA conducted the director of care and administrator interviews in the LTCF. All interviews were carried out using a set of semi-structured open-ended questions developed by the authors to encourage participants to describe their perceptions of barriers and enablers for new RN graduates to become effective supervisors in LTCF. Specifically, participants were asked the following questions: “How do you see the role/scope of practice of the RN/RPN?” “What are some regulations affecting nurse management, supervision, and leadership in LTC homes?” “What do you see as barriers to effective new RN supervision?” and “What do you see as the impact of a facility having highly effective new RN supervisors?” The interviewers used follow-up questions to probe for greater depth in participants’ responses related to skills required for LTCF. Consistent with the methodology, interview questions were structured to build on and add to what was previously reported about factors that influence supervisory performance, particularly from an educational and training perspective. The interview questions were pre-tested with one LTCF administrator, and no changes were required.
Analysis
Interviews were recorded and transcribed verbatim. Data analysis was guided by directed content analysis (Hsieh & Shannon, Reference Hsieh and Shannon2005) which is used to “validate or extend conceptually a theoretical framework or theory” (p. 1281). Upon completion of the data collection, the authors read the transcripts separately, looking for factors that influenced education and training of new RNs, which may have affected their supervisory experience in LTCF. One of the researchers (DP) initially coded the data, and another researcher (VB) reviewed the coding. Any discrepancies were discussed until consensus was reached. For the second step of the analysis, the researchers identified new categories and developed subcategories of both previously identified and new categories during the research team meetings. In the final step of the analysis, data were categorized using Bronfenbrenner’s (1977) three levels of factors that influenced supervisory performance of the new RN.
To ensure trustworthiness of the study findings, Lincoln and Guba’s (1985) criteria were used. Credibility was achieved through data triangulation of multiple interviews, and researcher triangulation was utilized throughout the data analysis process. Development of a study database using NVivo 10 served as an audit trail to strengthen the dependability and confirmability of the results. To address transferability, we used thick descriptions of participants, as well as the use of stakeholder’s quotes, to support the categories.
Ethical Considerations
Prior to commencement of the study, the University Health Network Research Ethics Board approved the study. Participation was voluntary, informed consent was gained prior to participation, and confidentiality was assured. All interviews were transcribed verbatim by a professional transcriptionist and were verified by the RA. Identifying information was removed, and all participants and sites were assigned code numbers.
Findings
The final sample included four urban-area facilities and one rural setting facility. Four of the facilities were for-profit and one was not-for-profit. The sample included one large facility with over 150 beds, two medium homes with 100−150 beds, and two smaller homes with fewer than 100 beds. Stakeholders who participated in the interviews included six deans and directors of various schools of nursing, as well as four policy advisors. The management sample consisted of six administrators, five directors of care (DOCs), and two assistant directors of care (ADOCs), for a total of 24 stakeholders. The 23 interviews (two educators were interviewed together) yielded significantly rich data to reach saturation, when no new subcategories were identified.
The characteristics of all the study participants can be found in Table 1. The majority of the participants were female (79%) with an average age of 52 years (range 35−75). Almost all of the participants were employed full-time (95.8%) and on average have been employed in their current position six years.
Table 1: Characteristics of the participants
Three levels of influence on the supervisory experience of the new graduate RN emerged from the data analyses. These influences are the stakeholders’ perceptions of the requirements new graduates must have to be leaders in LTCF. The three categories that correspond with the socio-ecological model were personal influences, organizational influences, and external influences (Figure 1).
Figure 1: Categories of influences on the supervisory experiences of new graduate RNs
Personal Influences
Embedded within this level are the requisite knowledge, traits, and skills a new RN must have in order to be an effective supervisor in LTCF. Stakeholders noted that excellent interpersonal skills, clinical competence, critical thinking skills, time management skills, the ability to manage change, fiscal responsibility, and the ability to listen and provide feedback to others about a different approach to resident care or a problem are essential skills. As one participant stated:
Well, you know, [RNs need to have] good communication, negotiating, being aware of the strengths of the limitations and just a lot of the soft skills knowing who it is they’re caring for in LTC. The residents they’re caring for and the families and how that you can sometimes assign the appropriate care giver for that family and their needs. Just kind of knowing the people that you’re working and get to be a match. (Educator 1)
Participants also noted that a new RN also requires ‘soft skills’:
I think they need to realise that the nurses are, you know, great when they graduate with all their academic training, but they need to be able to manage staff. It’s that soft skill, it’s so important; they’re not just reacting to like, you know, “I’ve got my degree”, well great, you know, I have one too, we all do. But how do I now motivate staff, when should I discipline, you know. (Administrator 1)
RNs in LTCF also require competencies in gerontological care, which may not have been addressed in their basic nursing preparation. One educator addresses this need:
You can have these skills, but if you can’t recognize … In long-term care, they have to know about all these aging problems. And they have to know about how families adjust, they have to know about grief, they have to know about mourning, and then they have to know how that’s going to affect other stuff. There’s no way they’re going to learn that when they’re in school, right − what’s it like when your colleagues have had so many people die? And how’s that going to affect the team functioning? There’s no way that they’re going to learn that in school. (Educator 2)
It was felt by most of the stakeholder group that essential qualities of the RN working in LTCF included knowledge, skills and competencies in soft skills, and management and care of complex older persons. Without these essential characteristics, newly graduated RNs struggle in their work environment.
Organizational Influences
The second level, organizational influences, addresses factors within LTCF that may impact the new RN’s ability to become an effective supervisor. Included within this category are the multiple role expectations of the new RN, the workload, and changes in the long-term care environment. Meeting the significant clinical and leadership responsibilities can impact the new RN’s ability to be an effective supervisor:
I think there’s a huge workload, for sure … and there’s so much to learn. And I know − recall being a new grad … worrying that you’re doing the right thing. And, you know, you have that sort of nagging at you, I guess, which is a good thing. To then go into a job where really those PSWs really rely on the RN. (Administrator 2)
New RNs working in LTCF have many other responsibilities that their peers may not encounter in acute care settings.
I look as the RN as more an extension of management when we’re not here, and the charge staff and their responsibilities and their scope is more than just resident care, but also the building care. (Administrator 3)
In addition, the workload is also more complex given the multigenerational workforce and the issues that can arise from the different cultural/ethnic backgrounds and age groups.
… you’ve got different types of backgrounds, the diversity of the workforce, and then, you know, within that the ability to accept direction from different backgrounds. That’s an interesting dynamic to watch, or the different ages. (Administrator 1)
A new graduate is often supervising a much more experienced PSW, which can impact the new graduate’s comfort level. This can potentially have negative consequences unless the new graduate is mentored appropriately:
But it’s very difficult because they’re [new graduate RNs] coming into a place where maybe a PSW has worked for 35 years, you know. She’s 20 and you’re 62 and you’re telling me what to do. (Administrator 4)
Today, there is more family involvement in LTCF, an emphasis on resident-centered care and residents who are sicker. All of these factors impact the supervisory role of the RN.
And I think that now it’s just more complex so they’re dealing with more complex things than perhaps – not that the nature of long-term care hasn’t changed, but as I tell everybody and I just told a bunch of RNs this morning for the Assistant Director of Nursing Care role. We are like a chronic care hospital. You know, 10 years ago we used to have all these chronic care hospitals dotted around Ontario and we don’t have those anymore. But that’s what we’ve become. So in that change also has resulted in, you know, responsibility everywhere, but particularly on the RNs, I think. (Administrator 5)
The role of the novice RN is influenced negatively by the workload, the complexity of the residents, and the reliance on the PSW to meet residents’ needs and provide high-quality care. Without the knowledge of how to lead teams effectively, this is a complex role for a new grad.
External Influences
The third level, external influences, refers to factors outside the control of the RN that impact the nurse’s supervisory performance. Examples of this are provincial regulations such as the Long-Term Care Act, and the College of Nurses of Ontario policy and practice standards. Nursing education programs as well as the broader nursing discipline’s perception of working in long-term care are included in this category.
The Ministry of Health and Long-Term care are the funders for LTCF. Legislation such as the Ontario Long-Term Care Act establishes regulations that all LTCF must follow in order to receive funding. These regulations impact the supervisory role of the RN and the documentation that must be completed in the nursing home in order to ensure compliance with reporting. Meeting the administrative demands of the role can negatively impact the new RN’s integrating the clinical responsibilities of the role.
So I feel as if while their scope is good they’re not able to really practice to their full scope. And that’s not because the regulation prohibits them from practicing to their full scope. It’s because it’s such a highly regulated environment and it’s so compliance driven that they’re primarily in their leadership role, doing a lot of reporting and administrative work that takes time away from their ability to, you know, integrate into the care team in a manner that gives them lots of time for direct supervision. (Policy Advisor 1)
The nursing regulatory body in Ontario establishes the standards of practice and the scope of practice that all registered nurses must follow. Due to the similarities in the scope of practice for both the registered nurse (RN) and the registered practical nurse (RPN) in the province, there is some confusion between the two nursing roles, which can cause gaps and delay in care. Moreover, this blurring of roles makes it more difficult for the RN supervisor to understand who is responsible for overseeing care needs of the residents, which can contribute to confusion in the workplace and potentially impact the job satisfaction of the registered nurses. As noted below, some administrators do not see a difference between the RN and RPN role in LTC.
I don’t think of them as separate, to tell you the truth. I think once you’re a registered nurse, RN, RPN, you’re a registered nurse. The only thing is that we have to have the 24/7 RN coverage in long-term care. Because we’re a [xx] bed facility, there’s ways I can get around that. If for some reason I don’t have an RN in the building, the manager can be on-call, and I can run the facility with just RPNs. So at the end of the day, at our facility they’re all the same. (Administrator 6)
Another external influence is the gap in educational preparation that affects the new RN’s preparedness for the reality of working in LTCF. To address the competencies that new graduates are expected to possess, most undergraduate nursing programs curricula are replete with courses and learning outcomes. However, these programs may not include the leadership competencies necessary to enable new RNs to have the knowledge and skills required to be successful in supervisory positions. Moreover, undergraduate baccalaureate nursing programs prepare the RN to be a generalist practitioner upon graduation; new graduate RNs may not have the opportunity to learn about funding models in long-term care, aging topics relevant to this setting such as dementia, or the Minimum Data Set (MDS) and how it impacts resident care in LTCF. These concerns were highlighted by stakeholders:
I think [teaching supervisory skills] something is still lacking in the university system… .[T]he universities are still very focused on “this is the theory”, you know, “these are the best practices”, and we’re teaching critical thinking skills … The universities don’t see themselves as contributing to the job environment; they don’t see that as a mandate. That’s college mandate, we’re training at college, we’re providing critical thinking at universities. (Administrator 7)
The final element is the wider negative societal perception of working in long-term care. For many nurses, long-term care is not seen as being a valuable or a rewarding job or career choice. The role of an RN in long-term care is sometimes viewed as an administrative, paper shuffling type of role, where RNs will lose their clinical skills and have limited career opportunities.
And I think that … well, my sense is that there’s a lot of turnover in the sector and there’s nurses that are leaving the sector. And my sister, my younger sister is a nurse, an RN and there’s no way in hell she’s going into long-term care. She did her practicum in a long-term care home and said she didn’t sign up to shuffle paper. And so that’s not where she wants to be but … and it’s a lot of responsibility straight out from school, taking on a leadership position in a long- term care home. And that wasn’t for her. (Policy Advisor 1)
Three levels of factors were found to influence the supervisory experience of new RNs: Personal characteristics and traits of the nurse, organizational impacts such as workload, and external forces such as ministry regulations impacted how the new RN performed the clinical and supervisory roles.
Discussion
The purpose of this study was to understand factors that influence supervisory performance of new RNs in LTCF settings from the perspectives of LTCF management, policy advisors, and educators. Rich descriptions of competencies, skills, and education that RNs received while in school were discussed by the stakeholder group. The stakeholders who knew the long-term care setting spoke to the challenges of working in the area. For other stakeholders, the exquisite skills required to master supervisory competency were lost on them.
The findings, specifically the three influences (personal, organizational, and external), may be similar for any new RNs starting their nursing careers. However, it is essential to consider the amount of responsibility the new RN faces when choosing to work in LTCF. In a LTCF, the new RN is responsible for more residents than a new RN would be expected to provide care for on an inpatient unit in an acute care setting. Moreover, in LTCF, a new RN is also responsible for overseeing care of a team largely comprising unregulated health professionals, while a new RN in most other practice settings would be working with licensed staff. The authors contend that the LTC environment provides additional challenges for new RNs to overcome when beginning their nursing careers in this setting.
The management stakeholders expect new RNs to possess the “soft skills”, have theoretical knowledge, and be clinical leaders and effective administrators, as well as to exhibit excellent relational and leadership skills. The educators told us that some leadership education is included in basic nursing education programs; however, the management stakeholders noted that this information is not sufficient or specific to LTCF. The discrepancy in perspectives between stakeholders can negatively impact the new RN’s experience in LTCF.
Knowledge and skills in relation to delegation and supervision, understanding of roles and scopes of practice of the employees in LTC, and building relationships with team members in LTC is also required to be an effective supervisor. Unfortunately, not all of the knowledge and skills can be part of the basic nursing preparation, which presents a conundrum in regard to how new RNs will acquire the essential knowledge and skills to work in LTCF. One recommendation is to include management theories and information on delegation to unregulated health care providers in nursing curriculums, to ensure nursing graduates have introductory exposure to the expectations of the RN leadership entry to practice role competencies.
In addition to the “soft skills”, the management stakeholders advised us that the RNs must have certain personal traits such as compassion. However, as one stakeholder put it, “compassion cannot really be taught”, but it is important in long-term care. Although communication and delegation theory can be taught in nursing programs, it cannot easily be enacted in practice. Through clinical practicums and the use of clinical simulation, students may have the opportunity to practice communication and delegation skills, but to truly feel comfortable and confident with these skills, they will require more experience working in LTCF. Stakeholders insisted that although educators can teach the theory, the new graduate RN needs time to be able to practice the integration of knowledge and skills in the long-term care setting and must be mentored.
It is evident from this study that educational programs are not sufficiently preparing new RNs to thrive in LTCF. There are inconsistencies on where new RN leaders should be educated to meet the demands of working in LTCF. In the end, it is the new graduate that suffers. Perhaps a solution such as nurse residency programs is required. Bowers (Reference Bowers2011) discussed the benefits that a nurse residency program in LTCF can have for improving the quality of care for residents, as well as improving retention of nurses. Providing educational workshops on topics pertinent to aging, as well as mentoring new RN employees, may assist with transition issues in the long-term care setting and increase retention in LTCF – a setting where RN turnover can be high.
Nolet et al. (Reference Nolet, Roberts, Gilmore-Bykovskyi, Roiland, Gullickson, Ryther and Bowers2015) reported on a long-term care clinical scholarship program (LTC-CSP) initiative, which is a 12-week paid summer internship in LTCF for junior or senior baccalaureate nursing students. In this program, students are prepared to work in a long-term care setting through use of ongoing workshops and supported learning opportunities, which assists in preparing these students for the realities of working in LTCF. In Ontario, there are limited new graduate guarantee initiatives funded by the Ministry of Health and Long-term Care. New RN graduates can be hired by LTCF and be supernumerary for up to a 26-week period, which enables the new RN to be mentored and have time to learn about specific topics relevant to LTC, such as the MDS, compliance rules, and the workload. This program enables the new RN to gradually transition to the supervisory expectations of the role after a six-month period. The caveat is that the LTCF must ensure there is a full-time job for the employee to transition to or provide another six weeks of full time employment (Health Force, Ontario, 2016). This may prevent some LTCF from participating due to the size of the facility and lack of funding for additional staff. Perhaps this initiative could be revised to enable smaller LTCF to be able to apply for this funding.
In order to develop strong initiatives to attract and retain new nursing graduates in LTCF, it is important to understand what key stakeholders perceive as determinants for retention. Nursing faculty and professional nursing organizations could support new RNs to be successful in LTCF from an educational and professional perspective. It is well known that supportive faculty can greatly influence the future employment decisions of new RN grads to work with older adults (Abbey et al., Reference Abbey, Abbey, Bridges, Elder, Lemke, Liddle and Thornton2006; Cozort, Reference Cozort2008; Prentice, Reference Prentice2012); therefore, faculty and deans’ efforts in promoting long-term care as a viable career could change the way current RN students perceive this as a work setting. Additionally, administrators and directors of care in LTCF have an important contribution to make in developing mentoring strategies to retain new RNs and support them with the knowledge and role development needed to succeed in LTCF.
Harvath et al. (Reference Harvath, Swafford, Smith, Miller, Volpin, Sexson and Young2008) suggested that leadership training for RNs working in LTCF should be viewed on a continuum, starting with basic nursing programs and continuing throughout the nurse’s career. Given the competing demands to provide a curriculum that covers all the competencies required of a new graduate RN and ensure success on licensing exams, not all topics can be completely covered in detail in the nursing education programs. The idea of a nurse residency program or an expanded new graduate initiative for all RNs who choose to work in LTCF would be ideal. This would require funding to be offered to new graduates who choose to work in this area of practice and would include tailored orientation and mentoring programs for new graduate RNs employed in LTCF.
To ensure consistency and quality of care, it is critical that new nursing graduates are retained in long-term care settings. Several initiatives to improve retention of new RNs have been suggested, including prolonged job orientation periods and the implementation of flexible shift schedules, to enable new graduates to find a work and personal life balance (Cheng, Liou, Tsai, & Chang, Reference Cheng, Liou, Tsai and Chang2015). Career planning and career development programs are other strategies used to provide support to new RNs (Waddell et al., Reference Waddell, Spalding, Canizares, Navarro, Connell and Jancar2015). All these initiatives are worthy, but have not been widely researched as to the effectiveness of retaining new RNs. Future research should focus on the workplace realities of the new RN in LTCF to ensure that we build educational programs to match their needs. The creation and evaluation of nurse residency programs in Canada, similar to the nurse residency programs in the United States, would be a good place to start.
Addressing societal attitudes towards the choice of working with older adults remains a challenge. It is not clear if these attitudes can be attributed to ageism or to the lack of desire to work in LTCF. Historically, nursing students’ attitudes towards working with older adults is reportedly negative (Gould, MacLennan, & Dupuis-Blanchard, Reference Gould, MacLennan and Dupuis-Blanchard2012; Happell, Reference Happell2002; Stevens, Reference Stevens2011). Although a more recent study shows that nursing students have positive attitudes towards older adults, they do not wish to work in LTCF (King, Roberts, & Bowers, Reference King, Roberts and Bowers2013). Discerning if the issue is ageism or disinclination to work in LTCF warrants further investigation.
Limitations
This study examined stakeholders’ perceptions from one province in Canada. Therefore, the findings may not represent the experiences of other stakeholders across the country.
Conclusion
The results of this study suggest that a discrepancy exists between management stakeholders’ expectations of new RN graduates and what these graduates learn in their formal education programs. Furthermore, for new RNs to be effective supervisors in LTCF, they are expected to have specific knowledge and skills, yet it is unclear how new graduates acquire these requisite skills. To ensure retention of RNs in LTCF, major changes must be implemented. In making the transition to bridge formal education and the requirements needed for RNs to be successful in LTC, initiatives must be developed, funded, and implemented across the country.
