Transitional Care Nurses' Self-Reported Characteristics of Work Areas, Job Satisfaction, Competencies and Need for Further Training: A Cross-Sectional Study

Introduction: Transitional care for older people with multiple chronic conditions is complex, and it is essential to identify the competencies of the nurses who provide such care. Aim: This study aimed to describe and compare the self-reported characteristics of transitional care nurses to their work areas, job satisfaction, competencies, and need for further training. Methods: A cross-sectional study design was used, and STROBE was followed for reporting. The total population of transitional care nurses (n=28) in Denmark was invited to participate. Data were collected through a questionnaire covering work areas, job satisfaction, competencies, and the need for further training. Results: Respondents reported high confidence in competencies related to direct clinical practice, cooperation and consultation, caregiver involvement, and use of electronic communication, and a limited need for further training. Expert transitional care nurses have high confidence in their work competencies related to patients and administrative tasks and increased job satisfaction.


INTRODUCTION
The population of older people with chronic conditions increases worldwide [1,2] in Denmark, one-third of the population is diagnosed with two or more coexisting chronic conditions [3]. The healthcare system is thus tasked with caring for an increasing number of older individuals with multiple chronic conditions [3]. The trajectories of older people with various chronic conditions are complicated by deficits in activities of daily living or risk factors such as social barriers. These individuals also experience challenges in managing their healthcare needs across hospital and municipal healthcare settings [4]. Therefore, it is essential to identify effective strategies to improve care transitions and outcomes for this population [4] and to identify healthcare professionals' required knowledge and skills to deliver effective transitional care [5]. Transitional care denotes the wide variety of time-limited services designed to ensure health care continuity and avoid preventable poor outcomes among at-risk populations as they move from one level of care to another, among multiple providers, and across settings [5,6]. According to Naylor and Van Cleave [6], a transitional care nurse (TCN) holds advanced knowledge and skills to care for vulnerable older people with chronic conditions. TCNs aim to provide care across settings in order to comply with individual and family caregiver needs, improve health outcomes and quality of life, and prevent frequent use of acute care and rehospitalization [6]. TCNs facilitate and are responsible for the complex transitions between hospital-and community-based care for older citizens with multiple chronic conditions [6]. Despite years of research into transitional care and related nursing roles, variations and lack of clarity about the characteristics of these nursing practices prevail. Furthermore, there is a lack of knowledge on TCNs' experiences and descriptions of their work tasks and consensus in the literature about how to describe and name the role of the nurses who facilitate transitional care [7,8]. Therefore, this study aimed to describe and compare the self-reported characteristics of transitional care nurses to their work areas, job satisfaction, competencies, and need for further training.

MATERIALS AND METHODS Design
A cross-sectional study design [9] was used to investigate and describe population characteristics at one point in time. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines for reporting observational studies [10] were used to report this study.

Participants and settings
The total population of TNC's (n=28) in the Danish region where the study was carried out were invited to participate in the survey in January 2021. They were employed at a university hospital (n=17) or in the hospitals' uptake area municipalities (n=11). The TCNs held different positions such as discharge coordinators, community care planners, ward managers, hospital coordinators. All were assigned the additional TCN role due to extensive work with transitional care trajectories. The TCNs did not receive any special education or training before taking on the TCN role, and their working conditions and experiences varied.

Measures
Data of the TCNs' work areas, job satisfaction, competencies, and need for further training were collected using a questionnaire based on three validated questionnaires [4,11,12] and demographic characteristics.

Demographic characteristics
Demographic characteristics included gender, age, years of tenure as a nurse, ongoing and/or completed education other than nursing school, and the place, position, and length of their current employment.

Work areas
Work areas were assessed using Hirschman and colleagues' nine Transitional Care Core Components: screening, staffing, maintaining relationships, engaging patients and family caregivers, assessing and managing risks and symptoms, educating and promoting selfmanagement, collaborating, promoting continuity, and fostering coordination [4]. Responses were measured on a seven-point Likert scale from 1 (strongly disagree) to 7 (strongly agree), with higher scores reflecting higher levels of agreement.

Job satisfaction
Job satisfaction was measured using the Job Satisfaction Scale (JSS) [11]. The scale consists of 15 items covering satisfaction with physical work conditions, colleagues, management, freedom in their work, recognition, responsibility, pay, opportunities, promotion possibilities, working hours, and job security [11]. Job satisfaction was measured on a seven-point Likert scale from 1 (strongly disagree) to 7 (strongly agree), with higher scores reflecting more significant agreement.

Competencies and need for further training
Self-reported competencies to manage clinical core components were measured using the Professional Nurse Self-Assessment Scale (PROFFNurseSASII) [12,13]. The scale consists of 50 items in six focus areas to avoid questions superfluous to the study aim. Only three out of the six focus areas were utilized for this survey: direct clinical practice (15 items), cooperation and consultation (6 items), and caregiver involvement and use of electronic communication (6 items). The selected 27 items were measured on two scales: 1) A-scale, covering the TCNs' self-assessment of competencies to handle the clinical core components, measured on a 10-point Likert scale from 1 (low level of competence) to 10 (high level of competence); 2) B-scale covering the TCNs' perceived needs for further training to handle the clinical core components, measured on a 10-point Likert scale from 1 (low level of need) to 10 (high level of need).

Validation of the final questionnaire
The final questionnaire consisted of 63 items. To strengthen validity [9] the questionnaire was sent to two nurses working with transitions and discharge in another region of Denmark for face and content validity. Their comments and corrections led to minor alterations in the questionnaire to consider translation issues after discussion and consensus amongst the authors.

Data collection
The TCNs individually received a link to the questionnaire in an email through SurveyXact (www.surveyxact.dk), and data were collected in February 2021. After one and two weeks, a reminder was emailed to those who had not replied.

Data analysis
Data were managed using descriptive statistics. The first author conducted the analysis using SPSS version 25.0 (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corporation). When appropriate, demographic characteristics are presented as numbers and percentages, with range, mean and standard deviation (SD). The results are presented as the mean and SD of the Likert-scale measures for work areas, clinical core component competency, and job satisfaction. Furthermore, the differences in mean scores between TCNs employed in the hospital versus municipal care settings were described.

Ethical considerations
The study was approved by the Danish Data Protection Agency (Reg-146-2020). When the TCNs received the link for the questionnaire, they were informed in writing about their legal and ethical rights. By replying to the questionnaire, the TCN's provided consent for participation.

RESULTS
Twenty-three TCNs (82.1%) responded to parts of the questionnaire, and 18 (64.3%) completed the questionnaire. Of the remaining five, two were on longterm leave, and three did not access the questionnaire.

Demographic characteristics
The TCNs were on average 44.22 years of age, ranging from 28 to 62 years. On average, respondents' tenure as nurses was 16.39 years (Table 1). Two TCNs (9%) completed an education after nursing school; a bachelor's degree and a master's degree, respectively. One nurse (4%) was undergoing further education at the bachelor's degree level. The TCNs were employed in a hospital (70%) or in a municipal care facility (26%); one TCN was employed in both (4%). The majority of TCNs had been employed in their current positions for less than two years (65%); six TCNs had been in their current position for three to six years (26%), and two TCNs had been in their positions for more than ten years (9%) ( Table 1).

TCN work areas
The work areas data analysis revealed that overall, TCNs employed at the hospital reported a higher agreement (5.61) with the work area statements than the TCNs from the municipal settings (3.94), measured on a 7-point Likert scale. The mean score was 5.24 in all nine work areas ( Table 2).
The TCNs had the highest work area agreement on the core component of "fostering coordination" (6.22) and secondhighest on" screening" (6.17). These core components also received the highest mean scores among hospital TCNs. The work area statements on "fostering coordination" (5.33) and "promoting continuity" (5.17) had the highest agreement among the municipal-employed TCNs. The lowest total mean score was reported for the core component "staffing" (3.43) ( Table 2).

Job satisfaction
The mean score of the TCNs' job satisfaction score was 5.71 measured on the 7-point Likert scale, with the highest scores reported for satisfaction with fellow workers (6.50), immediate boss (6.17), opportunities to use abilities (6.11), the attention paid to their suggestions (6.11), and their job security (6.06) ( Table 3). The TCNs' lowest measures area of job satisfaction were in opportunities for promotion (4.39) and rate of pay (4.17) ( Table 3).

Competencies and need for further training
The TCNs' self-assessed competencies and need for further training, measured on a 10-point Likert scale, are displayed in Table 4 following the main components of "Direct clinical practice," "Cooperation and consultations," and "Caregiver involvement and use of electronic communication" (Table 4) The TCNs' self-assessed scores for handling the clinical core components of "Direct clinical practice" were consistent and above the average score of 5 in selfassessed competencies and lower than five on the need for further training. In total, the TCNs assessed their competencies in direct clinical practice to be 6.87 on average, with a mean score of 6.80 for hospital TCNs and 6.58 for those in municipal settings. Indicating high confidence among the TCN's related to their ability to perform these tasks. The TCNs' highest self-assessed competency for the total counts was related to the core component of "I apply both subjective and objective methods when examining, treating and caring for patients." The lowest self-assessed competency was related to the core component of "I have knowledge of the interactions of various types of medication and what sideeffects they may cause for the patients I am responsible for." TCNs' self-assessed need for training in the "Direct clinical practice" component was 4.83 on average in the total count, 5.07 for hospital nurses, and 4.40 for those in municipal settings (Table 4).  The TCNs' highest self-assessed competencies were measured in the main component of "Cooperation and consultations," with 7.60 on average and a mean score of 7.47 for hospital TCNs and 7.61 for municipal TCNs. The highest self-assessed competency for the total counts was 8.89 on average in the core component of "I consult other professional experts when required," and the lowest selfassessed competency for the full count (6.06) was "I experience a division of responsibility between the physician and me as a nurse." The self-assessed need for training in "Cooperation and consultations" was 3.86 on average in the total count, 3.58 for TCNs at hospitals, and 4.28 for TCNs in municipal settings (Table 4). In total, TCNs assessed their competency in "Caregiver involvement and use of electronic communication" to be 5.92 on average, with a mean score of 5.62 for hospital TCNs and 6.47 for TCNs in municipal settings. The highest self-assessed competency for the total counts was 7.17 on average in the core component of "I focus on relatives' need for support and guidance." The lowest selfassessed competency for the total count (5.06) was "I assess the patients' health via telephone, email or other digital solutions." The self-assessed need for training in "Caregiver involvement and use of electronic communication" was 3.41 on average in the total count, 3.14 for hospital TCNs, and 3.72 for municipal TCNs (Table 4).  * Measured on a 10-point Likert-scale from 1 (low level of competencies/need for training) to 10 (high level of competencies)/need for training. **The TCN employed in both setting is included in te total count to secure anonymity.

DISCUSSION
This survey provided new knowledge regarding the TCNs' self-reported work areas, job satisfaction, competencies, and need for further training. The results revealed differences between TCNs' self-reported characteristics according to their employment setting, as the hospital TCNs reported higher average mean scores than TCNs in municipal care settings. The following sections address the observed differences within the studied domains. Although TCNs' work areas aligned well overall with the components in the Transitional Care Model [4], differences were observed between TCNs in hospitals (5.61) and community care (3.94). This might indicate more diversity and less standardization of duties in community-based settings. This is further underpinned by higher SD found in scores from TCNs employed in the community setting. Five out of six community-employed TCNs attended to administrative tasks rather than direct patient care, which might explain the diversity in the results. Administrative functions in community-based care have increased [14, 15,] and community care services are presently allocated by municipal authorities [16]. According to the Nordic Welfare Model [16], Danish municipalities are obligated to provide health and social care to everyone in need, regardless of their financial situation, social status, age, gender, or family situation. Some of the community-employed TCNs worked in positions that were not focused on direct nursing care, which might explain the generally lower ratings of work areas for municipal TCNs. The results might have been different if the community-employed TCNs had been more involved in direct patient care. This was supported by the results showing that the highest-rated work area for community-employed TCNs was the administrative function 'I prevent breakdowns in care from hospital to home,' while items related to direct patient care such as 'establish and maintain a trusting relationship,' 'engage older adults, and 'prepare older adults' were rated lower. By contrast, most hospital TCNs held the position of discharge coordinator, working in specific hospital wards. This allowed them to be physically present with patients, which might have resulted in higher ratings regarding 'engage with,' 'prepare' and 'establish relationships.' Overall, TCNs assessed their competencies in direct clinical practice above five on a 10-point scale. In addition, their perceived need for training in this realm was below five. This could indicate that the TCNs had high confidence in their competency in managing transitional care for patients. The confidence could stem from the average clinical experience of 16.4 years, based on which the respondents could be characterized as clinical experts [17]. This experience level implies an in-depth understanding of the holistic patient situation, guiding nursing practice above and beyond rules and principles [17]. Laws and principles provide essential guidance for novice nurses; however, the TCN function was new in this setting, and its rules and principles were not established [7]. When moving into a new field of practice, even experienced nurses have to practice at a lower level of experience [17]. Surprisingly, hospital-employed TCNs reported a higher need for "Direct clinical practice" training than the community-employed TCNs. This could be due to the predominantly administrative tasks of the community-employed TCNs, who assessed direct clinical competencies as less critical. A study by Erikcson and colleagues [15]1found that an increase in healthcare administrative tasks divert time and focus from more clinically important activities such as patient care. The low need for training reported to "Cooperations and consultations" could result from TCNs' high assessment of competencies in this area. In this area, the highest-rated competencies among all TCNs were "I consult other professional experts when required" and "I cooperate actively with other health professionals when coordinating the patient's nursing, care, and treatment." Collaboration with other health professionals is considered necessary in the transitional care of older citizens [4,6,7]. Hirschman and colleagues [4] describe how consensus on care plans for older individuals relies upon multidisciplinary collaboration to achieve a shared understanding of patient goals and decrease the burden on patients and families. The average job satisfaction score of 5.71 indicates moderate to high job satisfaction among the TCNs. The highest-rated areas demonstrated that colleagues and job security greatly influenced TCN job satisfaction, which has also been found to be important in similar studies [18,19]. Another aspect influencing high job satisfaction was the job content, including "opportunities to use abilities" and "attention paid to my suggestions." This may indicate that TCNs perceive their function as aligning well with their abilities as registered nurses and that they appreciate the creative task of discovering and testing different solutions with each patient situation. This aligns well with the dimensions of the "aesthetic knowledge pattern" identified by Chinn and Kramer [20] to describe the nurses using creative resources to enable new possibilities. The aesthetic knowledge pattern also implies an ability to 'sense the whole of a situation and a direct silent knowledge of 'what is essential in a situation [20].

METHODOLOGICAL CONSIDERATIONS
The sample of our study, consisting of 23 TCNs, could be considered too small for a cross-sectional study, and a limitation could be that we did not conduct a power calculation [9]. However, all TCNs within the investigated region in Denmark were invited to participate, meaning the total population was targeted. Using self-reported competency levels and training needs risks introducing a ceiling and floor effect, respectively. These effects occur as respondent answers cluster towards the highest or lowest possible scores, reducing variability [9]. This study would have resulted in respondents reporting very high levels of competency overall and low levels of need for further training. However, data collected for the current analysis did not indicate either of these effects, increasing data quality. Moreover, the competencies utilized in the questionnaire are theoretically developed to assess competency levels among nurses with an APN education and not registered nurses with an additional TCN role as in our study. This might have limited our results, but to the authors' knowledge, it is the closest and most transferable instrument to assess competencies of TCNs, even though the level of education is different.

CONCLUSION
Differences were detected between TCNs employed in the hospital versus community settings. Essential differences in work areas included hospital TCNs working closer and more directly with patients and municipal TCNs performing more administrative tasks than direct patient care. Despite these differences, all respondents reported high confidence in competencies related to direct clinical practice, cooperation and consultation, caregiver involvement, and use of electronic communication.
Overall, the TCNs were well experienced, with an average of 16 years of nursing experience, which might explain their self-reported low need for further training.

ACKNOWLEDGMENTS
We would like to thank the transitional care nurses for their time and effort in participating in our survey.

AUTHORS' CONTRIBUTIONS
The participation of each author corresponds to the criteria of authorship and contributorship emphasized in the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly work in Medical Journals of the International Committee of Medical Journal Editors. Indeed, all the authors have actively participated in the redaction, the revision of the manuscript, and provided approval for this final revised version.

FUNDING SOURCES
None.