Municipal elderly care: Implications of registered nurses' work situation, education, and competence

Registered nurses (RNs) are key figures in municipal elderly care. It is a challenge to create necessary conditions that enable them to provide quality nursing care. These studies aimed to increase insight into RNs work conditions in municipal elderly care, and to compare RNs working solely in dementia care (DC) with RNs working in general elder care (GC). The specific aims were to describe RNs’ perceptions of: (I) their work situation, regarding demands, influences, and social support, as well as RNs characteristics; (II) violence and threats directed at them, other staff, and care recipients, as well as access to prevention measures and routines for handling violence and threats; (III) their education and competence development; (IV) their needs for knowledge, possibilities for competence development, supervision, organisation of RNs’ development, financial support, competence utilisation, and managers’ competence. A descriptive and comparative design was used. The setting consisted of 60 special housing with subunits in a large city in the middle of Sweden. A total of 213 RNs participated, with a response rate of 62%. Of those, 95 (45%) worked in DC and 118 (55%) in GC. A structured questionnaire, designed for these studies was used. Study I showed on average high time pressure in both groups. Greater knowledge and higher emotional and conflicting demands were found in DC. The majority reported greater opportunities to plan and perform daily work tasks than to influence the work situation in a wider context. On average, there was a high level of support at work from management and fellow workers. Study II indicated that RNs had witnessed and experienced a high degree of indirect threats, direct threats of violent acts, and violent acts, with care recipients also subject to threats and violence. The RNs in DC had greater access to education in managing threats and violence, and routines for managing violence and a door with a lock to their working unit. Study III revealed that RNs possessed a broad range of formal competence. On average, the RNs had 18 years of work experience as an RN. The majority lacked a Degree of Bachelor in Nursing. Few had adequate specialist competence. RNs in DC were willing to invest more in competence development whereas RNs in GC were more motivated to invest in competence development by seeking another position and by attaining a greater authority to make important decisions at work. Study IV showed that, on average, the RNs did not lack or hardly lacked knowledge in the examined domains. RNs in GC lacked knowledge of dementia, falls, and fall injures to a greater extent than RNs in DC. RNs in DC perceived greater possibilities for competence development at work. Most RNs, especially in GC, requested a better organisation for competence development. The majority of RNs had no supervision. Although the utilisation of the competence of RNs was high, RNs used their highest competence about half of the working hours. The employers’ financial contribution to RNs’ continuing education was poor. Conclusions drawn from the studies are: (I) RNs’ time pressure needs to be decreased and their influence on decisions increased. (II) Violence occurs equally frequently without any difference between DC and GC. More often, RNs in DC are offered education on how to manage violence and threats, and have routines for management of violence. Therefore, municipal authorities should increase staff education for management of violence and creating safety routines. Violence needs to be taken seriously with a ‘zero tolerance’ attitude. (III) It is important to develop the RNs’ competence and increase the utilisation of their competence. It is also essential to increase the number of RNs who have specialist competence. (IV) Better organisation and greater possibilities for RNs’ competence development is needed. Employers need to make a greater financial contribution to RNs’ competence development. RNs also need supervision. When combined, high demands and low control in the work situation form the most critical combination for the health of RNs. This may lead to sick-absenteeism and staff turnover. Thus, RNs’ time demands should be decreased, violence be minimised, and influence in decision-making increased in both groups. Further research is required on RNs’ competence development, family conditions, leisure, health, their ‘ideal work’, and the concept of general elder care.