Competency and Educational Requirements: Perspective of the Rural Emergency Nurse☆

Article Outline

• Abstract
• Methods
• Results
• Discussion
• Limitations
• Implications for Emergency Nurses
• Conclusion
• References
• Biography
• Copyright

Introduction

Continuing education has been associated with maintaining clinical competency for nurses. Despite this information, the availability, time, and financial support to attend continuing educational programs challenge the ability to develop, provide, or attend such programs. Before the development of methods to provide continuing educational programs to nurses working in rurally located emergency departments, a survey was developed to capture the perspective of these nurses.

Methods

An investigator-developed survey was administered to emergency nurses working within an emergency department located in a rural Midwestern state. Consent was implied upon return of the survey, and response to the survey was voluntary, in accordance with our institutional review board's policy.

Results

Data were obtained from 33 nurses, representing 3 different rurally located ED settings. The perceptions of the participants of this study are that maintaining clinical competency is important and that ongoing continuing education should be mandatory.

Discussion

These data indicate that emergency nurses in rural areas are willing to participate in ongoing education and that maintaining clinical competency is valued. Using evidence-based data to develop continuing educational programs increases the potential for the programs to be appropriate and valued and more likely to be attended by these nurses.

Key words: Clinical competencies, Educational requirements, Rural emergency department, Registered nurses, Survey

Clinical competency among nurses working within specialty areas has been linked to initial and ongoing education. According to Judd et al,¹ education and clinical competency have been linked since the 1800s, the era of Florence Nightingale. Despite this link, variability exists with regard to policy, procedures, standards, and financial support for continuing education programs that focus on maintaining clinical competency.

In 2008 the American Nurses Association (ANA) published a position statement on registered nurse (RN) professional role competency.² This statement describes maintaining competency as a professional obligation. According to the ANA, competencies shall be measurable, definable, and able to be evaluated.² Individual nurses have the obligation to maintain competence in accordance with regulatory bodies and employers. The ANA publication Nursing: Scope and Standards of Practice outlines the expectations and required competence level for RNs.³ Each standard encompasses criteria by which quality of practice, service, or education can be evaluated. Standard 8 outlines the educational expectations of RNs. This standard states that “professional RNs are to acquire knowledge and skills that are necessary for specialty areas of practice.”³

In addition to the position standards of practice outlined by the ANA, the ENA provides information relevant to nurses working within an ED setting.⁴ The ENA endorses certification programs that promote competence and achievement in emergency nursing. In 1999 the ENA published Scope of Emergency Nursing Practice, which links competency to standards of excellence.⁴ These standards are useful in defining the responsibilities of RNs working within ED settings and provide measurable criteria for quality emergency nursing practice. Potentially, RNs within any emergency department setting may provide care to a wide range of patients—from pediatrics to geriatrics, from cardiac conditions to exposure to hazardous materials; thus it is essential to have an expansive clinical knowledge. In addition to acute care, RNs working in ED settings need to include wellness, safety, and prevention interventions where appropriate.

The National Council of State Boards of Nursing regulates standards of nursing practice and is charged with protecting the public from health care professionals who are unqualified and incompetent.⁵ On the basis of its own research, the National Council of State Boards of Nursing has concluded that passing an initial examination for licensure does not ensure competency, because of the constant changes in health care knowledge and changing technology.⁵ Ongoing education is vital for nurses to maintain clinical competency and ensure that evidence-based care is provided.

Clinical competencies and continuing education requirements vary among states and employers. Most employers use guidelines outlined by The Joint Commission and the Emergency Medical Treatment and Active Labor Act (EMTALA) to determine the number and content of required continuing education units (CEUs). Competency recommendations from The Joint Commission and EMTALA include basic life support, advanced cardiac life support, pediatric advanced life support, trauma nurse core curriculum, and additional education/training pertaining to triage and meeting the standards set forth by EMTALA.

A review of the literature failed to identify data that describe the ability of educational programs to maintain competency, from the perception of RNs who provide care within a rurally located emergency department. Data obtained from these individuals would describe the resources available, reflect perceptions, and be appropriate for use in developing CEU programs. It was hypothesized that financial considerations and years of RN experience would influence occupational satisfaction and the perception that maintaining competencies is of value.

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Methods 

The survey instrument, developed as part of a course project, underwent face and content validity activities by peer and expert review. Peer review occurred by having fellow students review the survey. Research and teaching faculty provided expert review. Spacing, placement of items, and readability suggestions were incorporated into the final survey, before submission to the institutional review board for approval to perform the study.

Study activities commenced once approval for the study was secured from the Social Science Institutional Review Board at the university with which we were associated. Potential participants in this study included healthy adult RNs who provided care in an ED setting. Study participation included voluntary completion of an 8-item survey and was considered to pose minimal risk. Thus study consent was considered to be implied upon completion and submission of the study survey.

All data were collected by use of the researcher-developed instrument. Items within this instrument allowed each study participant to describe himself or herself with respect to age, gender, educational preparation, overall years of nursing experience, and years of nursing in an emergency department. The availability of a nurse educator and the use of a preceptor/mentor program were assessed. Study participants indicated whether CEUs were required by their employers. Then, by use of a 10-point Likert scale (1, low; 10, high), they were asked to describe their perceptions regarding maintaining competencies, whether CEUs should be mandatory, and their overall occupational satisfaction.

The purpose and time requirement associated with study participation were described by one of the researchers during routinely held staff meetings. The surveys were distributed, along with preaddressed stamped envelopes. Each envelope was addressed to the faculty researcher, who served as the data manager for this study. If study participation was desired, each participant was instructed to complete the survey, place it in one of the envelopes provided, seal the envelope, and place it where appropriate for the institution to place it into the outgoing US mail system. This provided confidentiality regarding the responses, limited any influence of the Hawthorne effect, and prevented the researcher from knowing individual responses.

Once received, each survey was given a study number, and data were entered into a study-designed SPSS program (SPSS, Chicago, IL). Frequency, descriptive, and correlational techniques were used to determine whether financial considerations and years of RN experience influence occupational satisfaction and increase the perception that maintaining competencies is of value.

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Results 

Data were obtained from 33 RNs who provide care in a rurally located emergency department. Each survey was complete, and there were no stray or extraneous data in the survey responses. Once entered into the SPSS program, the paper copies of the survey were placed in a locked cabinet at the university and will be destroyed in accordance with its research policies. All analyses were performed on aggregate data, thus preventing the ability to link any individual response to a particular participant.

The “typical” RN participant in this study was a woman, aged between 39 and 54 years, with an associate degree in nursing and more than 14 years of nursing experience, the majority of which was spent in an emergency department not designated as a trauma center. Occupational satisfaction was high, rated between 7 and 10 on a 10-point Likert scale, and clinical competency was perceived as very important, receiving the highest score possible (10) on a Likert-type scale.

The Table demographically describes the RNs who responded to the survey. Occupational satisfaction was rated from 1 (low) to 10 (high) on a Likert scale; all responses scored a rating of 5 or higher. Occupational satisfaction scores were high. Of the participants, 10 (39%) rated their occupational satisfaction as 10, 19 (58%) rated their occupational satisfaction between 7 and 9, and 1 (3%) described their occupational satisfaction as moderate, with a rating of 5.

Table. Demographics of study participants

Demographic variable	No. (%)
Gender
Female	30 (91)
Male	3 (9)
Employment site
Trauma center	32 (97)
Non-trauma center	1 (3)
Age
20-30 y	5 (16)
31-38 y	2 (7)
39-46 y	9 (27)
47-54 y	8 (24)
55-62 y	5 (16)
≥63 y	3 (10)
Educational preparation
Associated degree	16 (49)
Diploma	4 (12)
Baccalaureate	8 (24)
Other	5 (15)
Nursing experience
≤5 y	6 (19)
6-23 y	4 (12)
14-21 y	10 (31)
≥22 y	12 (38)
Emergency nursing experience
≤5 y	12 (37)
6-13 y	4 (12)
14-21 y	6 (18)
≥22 y	11 (33)

Perceptions regarding maintaining competencies were also highly rated. By use of the same 10-point Likert response scale, all responses were at or above 5. Maintaining competencies is perceived as highly important, with 23 (70%) of the participants rating this item as 10 and an additional 8 participants (24%) describing this as important, with scores between 7 and 9. Maintaining competencies was described as moderately important, with a response of 5, by 2 participants (6%). In addition to the perception that maintaining competencies is important, 25 (76%) of these respondents also stated that emergency department–specific CEUs should be mandatory. Of the participants, 21 (64%) stated that CEUs are not a requirement of their job duties.

The availability of a specific nurse educator assigned to the emergency department was described by 17 participants (52%), with 15 (46%) stating that there was no one to serve in this capacity. One participant (three percent) did not respond. Orientation programs, using either a preceptor or mentor approach, was available 85% of the time (n = 28).

Cross-tabulation, the χ² test, and correlations were used to determine whether occupational satisfaction or perception of maintaining competency varied depending on any of the demographic variables. The only significant correlation was a direct correlation, and it occurred between age and occupational satisfaction, which approached significance (P = .072), and age and perception of maintaining competencies, which achieved significant (P = .001).

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Discussion 

The results of this study indicate that RNs who provide care in an ED setting perceive that maintaining competencies is important and should be mandatory. On the basis of their perceptions, 70% of these participants regard competencies as highly important, as evidenced by a mean score of all responses of 9.33 out of 10.0 (SD, 1.33). Thus these participants value CEU programs, even though 64% stated that they are not a job requirement.

Occupational satisfaction failed to correlate with any of the demographic variables, indicating that these study participants, regardless of age, years of experience, and educational preparation, were satisfied with their job and employer.

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Limitations 

Participants in this study consisted of RNs who voluntarily responded to the survey. As such, generalizability of these results to other geographic areas or emergency departments in urban areas should be done with caution. In the Midwest, ED nursing positions are infrequently available, reflecting a stable workforce associated with occupational satisfaction. At the time of data collection, there were a total of 52 RNs employed full or part time at the study sites. Although this reflects a 63% response rate, it is impossible to determine the response percentage for individual employment status.

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Implications for Emergency Nurses 

The results of this study reflect overall satisfaction with the occupational choice of an ED setting and a perspective that continuing education, for the purpose of maintaining competency, is valued. These data may be useful to administrators interested in employee satisfaction rates and retention. Despite the fact that mandatory CEUs are not universally required by the employers of these study participants, this activity was still desired. These nurses regard continuing education to be an important part of their career management and job satisfaction. CEU programs focusing on competencies, required by employers, are routinely available and financially supported by employers. Additional methods to secure CEUs are available through professional organizations. Although regulatory organizations and individual employers have requirements concerning CEUs, it is ultimately the individual RN's responsibility to maintain clinical competency.

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Conclusion 

Obtaining data that allow the RN to articulate preferences related to CEU requirements and maintaining clinical competencies provides an evidence-based foundation capable of ensuring that educational programs are appropriate and valued and meet the needs of these individuals. Time, financial constraints, and human resources in health care settings are challenges frequently encountered when providing clinical educational programs. As shown by our results, RNs—especially those aged between 47 and 54 years—who provide care in rurally based emergency departments valued being clinically competent. These RNs perceive ongoing, employer-provided CEU programs as the way to ensure that competencies are maintained.

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References 

1. Judd D, Sitzman K, Davis GM. A History of American Nursing: Trends and Eras. Sudbury, MA: Jones and Bartlett; 2010;
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2. American Nurses Association . Position statements: Professional role competencies. http://www.nursingworld.orgPublished May 28, 2008. Accessed February 7, 2010
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3. American Nurses Association . Nursing: Scope and Standards of Practice. Silver Spring, MD: Nursebooks.org; 2004;
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4. Emergency Nurses Association . Scope of emergency nursing practice. http://www.ena.orgPublished July 1999. Accessed February 8, 2010
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5. National Council of State Boards of Nursing. http://www.ncsbn.org. Accessed February 11, 2010.
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