**Prevalence of Comorbidities in Individuals Diagnosed and Undiagnosed with Alzheimer's Disease in León, Spain and a Proposal for Contingency Procedures to Follow in the Case of Emergencies Involving People with Alzheimer's Disease**

#### **Macrina Tortajada-Soler <sup>1</sup> , Leticia Sánchez-Valdeón 2,\* , Marta Blanco-Nistal <sup>3</sup> , José Alberto Benítez-Andrades <sup>4</sup> , Cristina Liébana-Presa <sup>2</sup> and Enrique Bayón-Darkistade <sup>2</sup>**


Received: 23 April 2020; Accepted: 12 May 2020; Published: 13 May 2020

**Abstract:** *Background*: Alzheimer's disease (AD) which is the most common type of dementia is characterized by mental or cognitive disorders. People suffering with this condition find it inherently difficult to communicate and describe symptoms. As a consequence, both detection and treatment of comorbidities associated with Alzheimer's disease are substantially impaired. Equally, action protocols in the case of emergencies must be clearly formulated and stated. *Methods:* We performed a bibliography search followed by an observational and cross-sectional study involving a thorough review of medical records. A group of AD patients was compared with a control group. Each group consisted of 100 people and were all León residents aged ≥65 years. *Results:* The following comorbidities were found to be associated with AD: cataracts, urinary incontinence, osteoarthritis, hearing loss, osteoporosis, and personality disorders. The most frequent comorbidities in the control group were the following: eye strain, stroke, vertigo, as well as circulatory and respiratory disorders. Comorbidities with a similar incidence in both groups included type 2 diabetes mellitus, glaucoma, depression, obesity, arthritis, and anxiety. We also reviewed emergency procedures employed in the case of an emergency involving an AD patient. *Conclusions:* Some comorbidities were present in both the AD and control groups, while others were found in the AD group and not in the control group, and vice versa.

**Keywords:** Alzheimer's disease; comorbidity; older adults; elderly

### **1. Introduction**

A general increase in life expectancy has caused an aging population and a resulting rise in the incidence of diseases that were less prevalent a few years ago such as neurodegenerative disorders [1]. At present, Alzheimer's disease (AD) is the most common type of dementia [2–17]. It was first described

in 1907 [9] by the German physician Alois Alzheimer [1], who diagnosed it in a 51-year-old woman. It was described as a disease characterized by an impaired memory, disorientation, and hallucinations leading to death [1]. Currently, AD is considered to be a neurodegenerative disease [1,9,11–13,15,17–20] that is progressive [4,11,12,17–20] and results in mental or cognitive dysfunctions [1,5,11,17].

AD has become a major world health problem affecting a continuously increasing number of people. In Spain, 500,000–800,000 people suffer from AD, a number expected to double by 2050 [2,3]. More specifically, it is calculated that 10% of the population aged ≥65 years and 50% of that ≥85 years will suffer from AD [18]. Aging, therefore, greatly increases the risk of AD [6,9,21], which by now has become a social and public health issue [1].

The main symptom of AD is the loss of episodic memory [4,9,10,14]. This is accompanied by other characteristic "warning signs" [4,6,9,20,22] namely:


### *1.1. Pathophysiology of AD*

The pathophysiology of AD is characterized by the occurrence of neurofibrillary tangles and neuritic plaques [2,3,5,10,12,17]. Several theories try to explain its onset [2–5,7,8,12,16,23,24] as follows:

**Amyloid theory** The essential element of extracellular deposits is the protein β-amyloid, which forms fibrils that aggregate and cause the development of diffuse and neuritic plaques. The β-amyloid protein is produced by an abnormal cleavage of the amyloid precursor protein (APP). Normally, the product of secretase α action is a soluble peptide that can be easily removed from the body. In AD, the cleavage is performed by β- and γ-secretases producing insoluble peptides that are removed from neurons. Microglial cells unsuccessfully attempt their removal, and this results in inflammation and nerve damage.

**Tau protein theory** The tau protein is the main component of intracellular deposits in neurons. It is a microtubule-associated protein, with microtubules being cytoplasmic structures involved in the assembly and function of the cytoskeletal network of cells including neurons. Tau acts as a microtubule stabilizer. In AD, Tau hyper-phosphorylation prevents its binding to tubulin and results in autoaggregation and formation of neurotoxic intraneuronal precipitates.

**Cholinergic theory** A decrease in the levels of the neurotransmitter acetylcholine in patients with AD causes a diminished performance of neural connections.

In addition to the three theories mentioned above, several other hypotheses have attempted to explain the etiology of AD, such as oxidative stress and glutamate-mediated excitotoxicity [7,12].

### *1.2. Risk and Protective Factors*

AD is associated with a series of risk and protective factors. A risk factor is understood as one that increases the probability that an individual will develop a health problem or disease; while a protective factor is one that reduces such probability. We present a list of such factors that are associated with AD as follows:

### **Risk factors** [4,19,21,23,25–31]


### **Protective factors** [21]

• physical, educational, intellectual and social activities, moderate consumption of alcoholic beverages, and a Mediterranean diet.

Establishing which factors are protective or risk-linked for AD patients is made difficult by these patients' inherent inability to communicate consistently. One way to approach this problem is by detecting comorbidities associated with AD and developing possible action protocols to be employed in emergency cases. The present study compared the comorbidities in a population of individuals aged ≥65 years and diagnosed with AD with those in an undiagnosed (control) population of similar characteristics, in the city of León, during 2019. In brief, the objectives of this work are as follows:


The cognitive or mental impairment that people with Alzheimer's disease present increases the difficulty they have in expressing themselves and manifesting their symptoms. Therefore, there is a need to study the comorbidities associated with Alzheimer's, and to examine possible protocols for action in the case of an emergency with these patients who have difficulty with expression and communication. This proposal for action protocols would facilitate emergency situations (such as triage in the emergency department) for these patients with other people, despite their difficulty with expression and communication.

### **2. Materials and Methods**

### *2.1. Population Study*

We performed an observational and cross-sectional study of the medical records of the populations under comparison. This involved a preliminary search strategy from primary and secondary bibliographic sources. A total of 200 individuals were analyzed, 100 from each of the 2 populations.

A significance study was conducted using GPower software to estimate the sample size [32], then, two groups were established, i.e., control and AD, each consisting of 100 subjects, which provided a confidence level of 90%, on the basis of a total population with AD estimated in 7000 individuals, in the León region of Spain [33]. The Alzheimer's Center León register contains 370 patients, with a proportion of them diagnosed with dementias other than Alzheimer's (fluctuating percentage of about 20% diagnosed with other types of dementia, primarily frontotemporal dementia, Parkinson's, and Lewy body dementia).

### *Int. J. Environ. Res. Public Health* **2020**, *17*, 3398

### *2.2. Literature Search*

The bibliographic search connected with the present study included the PUBMED, WOS, and CUIDEN PLUS databases. A number of inclusion criteria were considered as follows:


### *2.3. Data Collection*

The current study was complied with the rules of the Helsinki Declaration of 1975. It was approved by the Ethics Committee of León University Hospital according to Resolution #1929 of 26 February 2019.

The criteria for inclusion in the AD study group were:


The selection of subjects meeting these criteria was random. The criteria for inclusion in the control group were:


### 2.3.1. Alzheimer's Disease (AD) Group

Data were obtained from the Alzheimer's Comprehensive Care Center of León of the León Alzheimer Center. Each subject was identified by a code number to protect anonymity and confidentiality. This procedure was approved by the León Alzheimer Center and supported by signed agreements. Medical records were reviewed at random, reached the maximum number of individuals possible from the total number of people registered at the center, and met the inclusion criteria.

### 2.3.2. Control Group

Data corresponding to the undiagnosed population were collected from the León University Hospital.

Subjects who were undiagnosed in the general population with Alzheimer's disease, were randomly selected among those attending the Emergency Department of León University Hospital, for a few days, using the Gacela® computer program (León University Hospital, León, Spain), considering the following characteristics: age, sex, reason for admission, and medical history number. We used the Jimena® software (León University Hospital, León, Spain) to review and collect data, which included the pathologies suffered and the list of drugs taken by each individual. Each subject was identified by a code number to protect anonymity and confidentiality. This procedure was approved by the León Alzheimer Center and supported by signed agreements.

### 2.3.3. Data Processing

Data were stored and analyzed using an Office Excel® spreadsheet processor (2019 version) (University of León, Spain). The data analyzed for both groups included age, sex, comorbidities, and number of drugs taken. It is important to mention that diagnoses of comorbidities were uniformly identified by both primary care and continuing care physicians. They were entered into an SPSS version 24 computer statistical program (University of León, Spain), which was followed by analysis of the variables for each of the 2 populations to be compared with each other.

Additionally, action protocols to be used in the case of an emergency involving a patient with Alzheimer's disease were obtained.

### *2.4. Significance Studies*

Data significance level was calculated with Pearson's Chi-square, and a value of *p* ≤ 0.1 was considered to be satisfactory. As mentioned in Section 2.1., the 2 populations of 100 individual analyzed, in the present study, provided a confidence level of 90% and *p* = 0.1.

### **3. Results**

### *3.1. Sociodemographics*

### 3.1.1. Gender Distribution

The entire sample of 200 individuals comprising both the control and AD groups consisted of 61% women and 39% men. Figure 1 shows that the control group was composed of 47% males and 53% females; whereas the AD group consisted of 31% males and 69% females.

**Figure 1.** Alzheimer's disease and gender. This figure shows the number of men and women that make up both the control group and the Alzheimer's disease (AD) group.

### 3.1.2. Age Distribution

Figure 2 shows the comparative age analysis of the AD and control groups. This cohort study indicates that the number of subjects within the age interval 76–85 years is the largest in both groups. The age distribution of the AD and control groups clearly differs. The AD population shows an uneven

pattern, with the >85 years group placed second after 76–85 years and a clearly smaller 66–75-year-old group. Instead, the distribution is rather symmetrical in the control population. In brief, the age interval in the AD group is shifted to older ages as compared with the control population.

**Figure 2.** Age range distributions of the AD and controls. This figure shows the distribution of both the control group and the AD group, into three age range groups.

### *3.2. Pathologies*

The comparison of the AD group with the control group and the analysis of the pathologies observed in the populations under study shows three clear age range groups according to their higher, similar, or lower incidence of pathologies.

### 3.2.1. Pathologies with a Higher Incidence in the AD Group

Table 1 shows the percentages of individuals with comorbidities more abundant in the AD group than in the controls. The pathologies in question are cataracts, urinary incontinence, vitamin D deficiency, osteoarthritis, hearing loss, osteoporosis, and personality disorders.



The percentage of individuals not affected by these comorbidities are the remaining quantities up to 100, since in each group there are a total of 100 individuals.

Cataracts, urinary incontinence, and vitamin D deficiency affect 21%, 38%, and 11% of the individuals in the AD group, respectively, doubling the values observed in the control group, which are 12%, 16% and 5%, respectively. The difference is even more pronounced for osteoarthritis, which was present in 26% of the individuals in the AD group as compared with 9% in the control group. Strikingly, only 1% of individuals (one subject) was affected by hypoacusis, osteoporosis, or personality disorder in the control group, while the values were 13%, 20%, and 12% in the AD group, respectively.

In particular, emphasis is placed on the relationship between osteoporosis and gender.

Figure 3 shows the difference in prevalence of osteoporosis between men and women in the control and AD groups. As indicated in Table 1, 1% of women in the control group have osteoporosis while there are no cases of men. In the AD group, a total of 17% of women and 3% of men have osteoporosis.

**Figure 3.** Osteoporosis' disease and gender. This figure shows the percentage of men and women who have osteoporosis, differentiated into the two groups under study.

Table 2 indicates the Pearson's Chi-square values and significance levels for the comorbidities shown in Table 1.


**Table 2.** Chi-square data and significance values for cataracts, urinary incontinence, vitamin D deficiency, osteoarthritis, hypoacusis, osteoporosis, and personality disorders.

\* The Chi-square statistic is significant at the level 1.

The significance levels of cataracts, urinary incontinence, osteoarthritis, hypoacusis, osteoporosis, and personality disorders were 0.086, <0.00, 0.002, 0.001, <0.00, and 0.002, respectively. These values were lower than the p-value of 0.1. Instead, vitamin D deficiency showed a significance level value of 0.118, i.e., higher than the *p*-value. Therefore, we can say that the differences observed for the conditions listed on Table 2 are significant, except for vitamin D deficiency.

### 3.2.2. Pathologies with a Lower Incidence in the AD Group

Table 3 shows the percentages of individuals with comorbidities less abundant in the AD group as compared with the control group. The comorbidities which were analyzed included eye strain (increase in intraocular pressure), stroke, vertigo, hyperuricemia, circulatory insufficiency, atrial fibrillation, and respiratory insufficiency.

**Table 3.** Presence of comorbidities with lower incidence in the AD group.


The percentage of individuals not affected by these comorbidities are the remaining numbers up to 100, since in each group there is a total of 100 individuals.

The AD group shows 2%, 1%, and 2% of individuals affected by eye strain, stroke, and vertigo, respectively; whereas the values in the control group are higher, i.e., 5%, 11%, and 14%, respectively.

The percentages of control individuals affected by hyperuricemia (increased uric acid in the blood), circulatory failure, and atrial fibrillation are 14%, 34%, and 11%, respectively. In the AD group, those percentages are 9%, 21%, and 7%, respectively; all of them lower than in the undiagnosed population. The percentage of individuals with respiratory failure is 25% in the control and 4% in the AD group, indicating an incidence five times higher in the control group.

Table 4 shows the Pearson's Chi-square values corresponding to the comorbidities listed on Table 3.

**Table 4.** Chi-square data and significance values for eye strain, stroke, vertigo, hyperuricemia, circulatory failure, atrial fibrillation, and respiratory failure.


\* The Chi-square statistic is significant at the level 10. <sup>b</sup> More than 20% of the cells in this subtable had predicted cell counts less than 5. The Chi-square results may not be valid.

The significance levels of the comorbidities eye strain, stroke, dizziness, circulatory insufficiency, and respiratory insufficiency are all below the *p*-value of 0.10. In contrast, the comorbidities hyperuricemia and atrial fibrillation have a significance level of 0.268 and 0.323, respectively, i.e., higher than the *p*-value of 0.10. Thus, we can say that the differences observed for the conditions listed on Table 4 are significant except for hyperuricemia and atrial fibrillation.

### 3.2.3. Pathologies with a Similar Incidence in both Populations

Table 5 shows the comorbidities that do not show significant differences based on a comparison of the control and AD populations.



The percentage of individuals not affected by these comorbidities are the remaining numbers up to 100, since in each group there is a total of 100 individuals.

The proportions of individuals affected by type 2 diabetes mellitus, glaucoma, depression, obesity, arthritis, anxiety, and heart disease in the AD group are 19%, 6%, 27%, 7%, 8%, 14%, and 31%, respectively. In the control group, these values are 20%, 6%, 26%, 7%, 9%, 12%, and 26%, respectively. The figures show a similar incidence of these comorbidities in both the AD and control groups. The comorbidities arterial hypertension and dyslipidemia present a relatively high incidence in both the control and AD groups; with values, in the AD group, of 51% and 45%, respectively and, in the control group, the corresponding percentages are 64% and 39%, respectively.

Table 6 shows the significance levels of the comorbidities type 2 diabetes mellitus, glaucoma, depression, obesity, arthritis, dyslipidemia, anxiety, and heart disease are all well above the *p*-value of 0.10. Instead, hypertension shows a significance level of 0.063, which is lower than the *p*-value of 0.10. Thus, we can say that only the differences observed for hypertension are significant.


**Table 6.** Chi-square data and significance values for type 2 diabetes mellitus, glaucoma, depression, obesity, arthritis, hypertension, dyslipidemia, anxiety, and heart disease.

\* The Chi-square statistic is significant at the level, 10.

### *3.3. Medication*

The number of medications taken by individuals from both study populations shows an average number of seven for each group, with the most abundant range being 6–10 medications.

Figure 4 shows that individuals in the control group took a larger number of drugs as compared with the AD group, with no one in the AD group taking >15 drugs. Nonetheless, the average number of drugs taken by each individual is the same (*n* = 7) in both groups.

**Figure 4.** Number of medicines prescribed in the control and AD populations. This figure shows the amount of medication taken by subjects belonging to both the control and AD groups.

### **4. Operating Procedures in the Case of Emergencies**

This section outlines the analyses of possible courses of action in the case of emergencies involving AD patients. We re-examined the standard operating procedures employed in the two centers from which the data presented here were collected, namely the Alzheimer's Comprehensive Care Center and the León University Hospital (León, Spain) (Table 7).



This table compares different points between the Protocol of the Alzheimer's Center León and the Protocol of the University Hospital of León

The protocol for the Alzheimer's Comprehensive Care Center regarding patients with Alzheimer's disease is focused on the prevention of falls and an action plan should a fall occur; whereas the protocol for the León University Hospital refers to the activities the nursing staff should perform according to the different nursing diagnosis lists of the NANDA (North American Nursing Diagnosis Association), for individuals with AD. The main difference between these two action protocols is that while that for the León University Hospital is exclusively directed to the nursing staff, the Alzheimer's Comprehensive Care Center's protocol is aimed at all its workers. Each of these approaches has different characteristics. A protocol of action, exclusively in the hands of the nursing staff, is based on their qualifications and competence to handle AD patients, and is standardized and excludes individual initiatives, thus, eliminating additional variables. An action plan aimed at all the workers dealing with AD patients has to be centered on the needs of such patients and must contemplate the fact that less qualified workers should seek professional advice whenever in doubt or when faced with unexpected events.

Fall prevention can require the physical restraint of AD patients, which must only be performed by medical order. In this respect, both centers have a specific protocol. When restraint requires the use of straps, the patient's skin integrity is first assessed. Importantly, the subjects in question and their relatives must be informed. Furthermore, the Alzheimer's Comprehensive Care Center's protocol contains a scale of evaluation of fall risks according to the J.H. Downton scale [34]. This evaluation has been applied to all the individuals in this center, who are professionally supervised depending on their individual risks. The reliability of the risk scale must be regularly reassessed. The León University Hospital's protocol does not use any scale to assess the risk of falls and simply considers the nature of the mental state alteration of each AD patient, for example, dementia, delirium, etc.

The Alzheimer Comprehensive Care Center also considers some intrinsic and extrinsic factors that affect fall risks. Classical intrinsic factors are age, medicines taken or associated comorbidities; while extrinsic factors are of an environmental nature, for example, inappropriate floor surfaces, lack of appropriate equipment, among others.

### *Procedures in the Event of a Fall*

Intervention in the case of a fall is protocolized in the Alzheimer Comprehensive Care Center but not in the León University Hospital.

The first step of the intervention is to help the person who fell, as well as reassure other individuals in the vicinity who witnessed the event. The latter is essential since AD patients are particularly sensitive to traumatic situations even if not personally involved, and their behavior can be altered. The second step is a professionally conducted evaluation of the fallen patient's condition, with the help of an emergency team if necessary. It is extremely important to examine in detail why the fall occurred, in order to detect its possible causes, and therefore prevent other falls. It is equally important to consider the associated comorbidities of the patient, which may impinge on the action protocol to be used.

### **5. Discussion**

The purpose of this work was to study the prevalence of comorbidities in an AD population as compared with a control population. First, we confirmed that the probability of developing AD is associated with an older population and is more frequent in females, in agreement with previous studies [26]. Presently, there is a debate as to whether AD is more prevalent among women due to genetic reasons or as a result of their longer life expectancy, which would make them more susceptible during later years.

Østergaard et al. (2015) [19] and Gallego and Guerrero (2017) [21] proposed that certain cardiovascular factors could facilitate the appearance of Alzheimer's disease. Among them, they mentioned high blood pressure, type 2 diabetes mellitus, heart disease, dyslipidemia, and obesity. This view was shared by Dugger et al. [25]. Our results do not fully support these suggestions. In fact, we detected a lower incidence of arterial hypertension in the AD group as compared with the control group, which was significant (Tables 5 and 6). No differences were observed between the AD group and the control group regarding the incidence of type 2 diabetes mellitus and obesity (Table 5). On the contrary, the incidence values for dyslipidemia and cardiopathy, although non-significant (*p* ≥ 0.1), indicate a higher prevalence in the AD group.

In our study, the incidence of glaucoma, depression, anxiety, and arthritis was similar, though not significant, in both the AD and control populations. Xu et al. [35] claimed, in 2019, that the correlation between glaucoma and Alzheimer's disease was due to an enhanced susceptibility of AD patients to glaucoma. Depression and anxiety were described as AD predisposing factors by Ehrenberg et al., in 2019 [36]. Kao et al. [37] proposed that the correlation between arthritis and AD was actually an inverse relationship. According to our observations, there is a higher incidence of a history of stroke in the control group as compared with the AD group. The difference was significant and disagrees with previous studies by Nucera and Hachinski [27] and Hachinski [38], published in 2018, which showed that a previous history of stroke predisposed AD.

The comorbidities that we observed to be less prevalent in the AD group are ocular tension, vertigo, hyperuricemia, circulatory insufficiency, atrial fibrillation, and respiratory insufficiency. They are all significant except for hyperuricemia and atrial fibrillation. Lu et al. [39] reported, in 2017, a lack of a clear relationship between hyperuricemia and AD. No clear link between atrial fibrillation and AD was found by Ihara et al., in 2018 [40], while a positive correlation with AD was observed for vascular dementia.

The following comorbidities were found to be much more prevalent within the AD group as compared with the control group: cataracts, urinary incontinence, vitamin D deficiency, osteoarthritis, hearing loss, osteoporosis, and personality disorders. With the exception of vitamin D deficiency, their incidence values were all significant. In particular, in Figure 3 it is possible to see that there is a higher prevalence of osteoporosis in women than in men. This fact causes us to consider whether this comorbidity is associated with sex rather than a diagnosis of Alzheimer's disease. For this reason, it is necessary to go deeper into the relationship between osteoporosis and Alzheimer's disease and to see the factors that cause this comorbidity in patients with Alzheimer's. The vitamin D deficiency results, though not significant, agree with those of Annweiler et al. [41] and Chen et al. [42]. The latter also found, similar to our findings, that osteoporosis appears to be associated with Alzheimer's disease. Similarly, Lee et al. [43], Swords et al. [44], and Rouch et al. [45] reported the association of AD with urinary incontinence, hearing loss, and personality disorders. The fact that the AD group consists of more women (69%) than the control group (53%) may explain the higher incidence of osteoarthritis for the AD group [46]. Similarly, the fact that it is composed of an older population could also explain that this group of subjects has a greater number of associated comorbidities, not incidents in the same way as for the control group [46].

Altogether, our results show a satisfactory number of coincidences, as well as some discrepancies with those from other investigations. The discrepancies found could be due, among other possible aspects, to the difference between the sample size of our study with that of the other investigations or to the subjects chosen at random in one study or another.

### **6. Future Research**

The observations reported, here, encourage further studies. First, an extension of the present research involving a greater number of patients and controls would be advisable. Secondly, longitudinal follow-up studies would allow the analysis of the existing and developing comorbidities of AD patients over long periods of time. As far as the Alzheimer's-free population is concerned, longitudinal studies would enable the detection of people that develop AD related to ageing. It would be possible to document whether the comorbidities they already suffered from were affected or not after the onset of AD, or whether the comorbidities were in any way related to the onset of AD itself. Such retrospective studies would obviously require a thorough analysis of medical records over long periods of time.

**Author Contributions:** Conceptualization, M.T.-S., L.S.-V., M.B.-N., C.L.-P., and E.B.-D.; Formal analysis, M.T.-S., J.A.B.-A., and E.B.-D.; Investigation, M.T.-S., L.S.-V., M.B.-N., and C.L.-P.; Methodology, M.T.-S., L.S.-V., M.B.-N., J.A.B.-A., and C.L.-P.; Software, J.A.B.-A.; Supervision, E.B.-D.; Validation, M.T.-S. and L.S.-V.; Visualization, J.A.B.-A.; Writing—original draft, M.T.-S., L.S.-V., and E.B.-D.; Writing—review & editing, L.S.-V., J.A.B.-A., and E.B.-D. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Acknowledgments:** The authors would like to thank each of the people who participated in this project, all of them in a selfless way. Especially, Flor de Juan, Director, and Laura Fuentes, Neuropsychologist, both from the Alzheimer's Day Care Centre of León, for providing us access to the Centre and collecting data. To Beatriz Abad, nurse of the León University Hospital, who helped in the collection of data from the control group, and finally, to Rodolfo Garcia for the exhaustive review of the manuscript.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*

### *Article* **Barriers and Facilitators Perceived by Spanish Experts Concerning Nursing Research: A Delphi Study**

**Alberto González-García 1 , Ana Díez-Fernández 1,\*, Noelia Martín-Espinosa <sup>2</sup> , Diana P. Pozuelo-Carrascosa <sup>2</sup> , Rubén Mirón-González <sup>3</sup> and Montserrat Solera-Martínez <sup>1</sup>**


Received: 6 April 2020; Accepted: 5 May 2020; Published: 6 May 2020

**Abstract:** The identification of research priorities in line with current health needs and nursing competencies is a priority. Nevertheless, barriers and facilitators perceived by nurses to performing nursing research have scarcely been investigated. The main aim of this study was to explore the situation in nursing research in Spain, as perceived by Spanish experts. A Delphi study technique in two phases was applied using an online survey tool. A panel of 20 nursing experts in nursing, teaching and management positions participated. The strengths highlighted were the possibility of reaching the PhD level, the possibility of receiving continuous training in research methodology, and access to scientific knowledge through the Internet. The weaknesses identified were the lack of Spanish nursing journals in which to publish the research results, the lack of funding in nursing care research, and the lack of connection between the healthcare institutions and the university. According to the experts, elements that could enhance leadership in research are the creation of nursing research units in hospitals, the economic recognition of nurses with PhDs, and considering research work as part of their daily tasks in clinical settings. The idea of being subordinated to physicians still remains in nurses' ways of thinking.

**Keywords:** nurses; nursing research; Delphi method; consensus; Spain

### **1. Introduction**

Over the past two decades, several factors have led to an increase in demand for qualified nursing care: changes in providing health care, economic cutbacks in healthcare organization, and technological developments. Bäck-Pettersson et al. [1] have suggested that nursing research should be geared towards the study of principles for effective and efficient nursing practice and factors affecting perceptions of health and well-being among individuals, families, communities and healthcare services.

The changes which nursing has undergone in Spain in the last two decades, both at an academic and professional level and as to the evolution of the health system, have drawn a favorable framework for the progressive incorporation of nursing professionals in the activities of scientific knowledge generation and communication [2]. Thus, the identification of research priorities in line with current health needs and nursing competencies is a priority in itself.

The Delphi method has been shown to be a widely used and flexible method that is particularly useful in achieving consensus in a given area of uncertainty or lack of empirical evidence [3]. It seeks to

gain the most reliable consensus of a group of experts by answering a series of sequential questionnaires or "rounds" intermingled by controlled feedback [4,5]. The Delphi technique has been used in a wide variety of nursing research, such as for determining the priorities of nursing administration research [6] and for the delivery of health care to children [7–9]. With regards to the academic field, the quality of nursing doctoral education and strategic directions for improving quality have been pointed out [10], as well as the identification of characteristics and essential elements of lifelong learning [11,12].

To our knowledge, only one study has tried to identify the barriers and facilitators perceived by nurses to the use of nursing research [13], focused on the Chinese context. The main difficulties identified were lack of authority, lack of time, language difficulties, lack of financial resources and lack of legal protection. The elements in favor were an improvement in management support, the promotion of education to increase the knowledge base and the moderate increase in the time available for implementation. The health center, academic training, and knowledge of the theoretical basis of evidence-based nursing were the factors that influenced these barriers and facilitators' perceptions [13]. Nevertheless, interest in Spain has been focused on establishing research priorities in healthcare [14,15], but not in identifying the weaknesses, threats, strengths and opportunities to research in nursing. In both cases, a list of closed priorities that had been previously agreed upon in a working group was used, but professionals in the field of clinical practice were not included in the group of experts.

It has been recommended to periodically reevaluate the academic programs of the nursing teaching centers to ensure that their approach is adapted to the current challenges, thus improving productivity [16]. In a context in which research excellence is a priority [17], and taking into account that access to external funding sources for the development of research projects requires a high competitive level, it seems logical to examine the current situation to know if it is necessary to make changes. In this sense, the Delphi method itself can provide elements for planning future scenarios [18].

Nurses play a pivotal role in the delivery of effective health care [8]. Considering that nurses and midwives comprise almost 40% of the healthcare workforce, the care that they deliver has a significant impact upon patient outcomes [19]. However, concerns about whether nurses and midwives use the best available evidence to guide their clinical practice have been noticed [20,21]. A lack of research use by nurses and midwives has potentially damaging consequences, with up to 30–40% of patients not receiving appropriate care [22].

For this reason, the main aim of this study was to explore the situation in nursing research in Spain, as perceived by Spanish experts. Secondary aims were to create a consensus on barriers and facilitators to delimit the characteristics of nursing research in Spain at present, and, finally, to identify the difficulties that clinical-care nursing professionals encounter in carrying out this task.

### **2. Methods**

### *2.1. The Delphi Method*

This study was conducted using the Delphi method. This method of study was developed in the 1950s by the RAND Corporation for military use [23]. The Delphi approach is a structured process that utilizes a series of questionnaires or rounds to gather and to provide information without the need for face-to-face meetings. The process continues until group consensus is reached. It is growing in popularity, especially for nurse researchers and for health research in general. It provides a relatively rapid and efficient way to obtain agreement from a wide variety of key informants by presenting a series of questionnaires for ranking. Maintenance of participation levels at 50% to 80% is crucial in reaching the consensus [24].

Google forms™ was used as the vehicle for distribution of the questionnaires. Participants were provided the link to the questionnaires through email correspondence. The study had two rounds.

In addition to sociodemographic and educational characteristics of the panel members, which are regarded as crucial to enable assessment of their credibility, round one was used to generate ideas [25]. Participants were asked two open-ended questions, thus allowing panel members freedom in their responses. These questions were (a) "Comment and describe what are the main strengths, opportunities and elements in favor of nursing in order to carry out your research activity. In other words, what facilitates and/or would facilitate our research work?"; and (b) "Comment and describe what are the main weaknesses, threats and difficulties and elements against nursing in order to carry out your research activity. In other words, what obstructs or would hinder our research work?".

Two researchers read the responses from the open-ended questions in the round one independently, searching for relationships and patterns and classifying them into clusters of similar ideas. The most commonly occurring attributes and concepts were identified and grouped into similar ideas. To validate the concepts that occurred, the individual notes were compared, and a third researcher evaluated the areas that deferred. Two researchers developed then the concepts that most commonly occurred into statements that retained the panelists' collective conceptual meaning. Statements were finally classified into four categories, following the structure of a strengths, weaknesses, opportunities and threats (SWOT) matrix. The number of items generated was 80. After that, two different researchers classified every item into seven main categories created ad hoc: nursing environment, academic level achieved, health administration, support for research from health administration, PhD issues, academic background, and nursing profession.

In round two of the study, participants were asked to rate their agreement with a Likert scale with numerical values attached to the scale range: zero (0) indicated strongly disagree and ten (10) indicated strongly agree. Data were collected between November 2016 and March 2017.

### *2.2. Sample*

Purposive sampling stratified by clusters was used for creating the panel of experts. An expert has been defined as one of a group of informed individuals and specialists in their field or someone who has knowledge about a specific subject [25]. Purposive sampling has been widely supported as an appropriate method of sample selection, especially in qualitative research [26]. The most important requisite of purposeful selection is the identification of experts in disciplines or domains directly and indirectly represented in the research instrument or topic under discussion. In addition to this, purposive sampling within maximum variation sampling is one way to obtain representativeness and rich data by including a wide range of extremes [27]. Maximum variation or heterogeneity sampling is described as a special kind of purposive sampling, which may be used to identify experts or cases (in qualitative research) to provide rich information [27]. This sampling method aims to identify themes or patterns that run through a range of variations.

Taking everything into account, the panel of experts consisted of four clusters: (1) nurses actively working at hospitals or primary health-care centers; (2) nurses working as a lecturer or full-time professor at the university; (3) nurses in a management position at a hospital (managing directors or directors of nursing); and (4) nurses in a management position at the university (dean, vice dean or head of the nursing department). These clusters include the professional fields of a nursing professional in Spain.

Regardless of the group to which they belonged, the research team considered it of great importance that the panelists show active research activity, given the topic of the proposed study. For this reason, active research activity was verified prior to its inclusion in the panel of experts in the form of a minimum of five papers indexed in Web of Science (WOS). There is little agreement about the size of the expert panel. Sample size and heterogeneity depends upon the purpose of the project, design selected and period for data collection. For the conventional Delphi, a heterogeneous sample is used to ensure that the entire spectrum of opinion is determined. Moreover, anonymity provides an equal chance for each panel member to present and react to ideas, unbiased by the identities of other participants. Reactions are given independently, so each opinion carries the same weight and is given equal importance in the analysis [25].

A reference group of twenty nurses representing all the clusters mentioned above was regarded as a convenient group of informed individuals and specialists with the requisite expert knowledge concerning nursing research, thus qualifying them as panel members. The principal investigator emailed them individually, explaining the characteristics of the study and proposing them to be part of the panel of experts. All of them responded positively to the invitation.

### *2.3. Validity*

Content validity was enhanced in some respects. Firstly, open-ended questions from round one and statements from round two were pretested with a representative sample of nurses to ensure that the concepts included in the study were clear. Secondly, the purposive study sample was comprised of a panel of experts who actively participate in nursing profession [28], so that they are representative of the area of knowledge [29]. Thirdly, successive rounds of the questionnaire increase the validity. Finally, the validity of results will be ultimately affected by the response rates [25]. Nevertheless, the findings should be regarded as expert opinions rather than indisputable data, and the validity and credibility of the research depends on the accuracy of conducting and reporting in the study. It is also important to be aware that the results only represent one moment in time [3,24].

### *2.4. Ethical Considerations*

The Ethics Committee of the "Virgen de la Luz" Hospital approved the protocol (registration number 2016/PI0116). Each participant was assigned a code to protect his or her data and affiliation. Informed written consent was required by email. Information was provided on the purpose, risks, benefits and social implications of participation. The right to refuse participation, to decline to answer questions posed or to withdraw at any stage of the process without any penalty or consequence was assured prior to eliciting participation. The ethical principles of the Declaration of Helsinki and the Oviedo Convention of Human Rights and Biomedicine were followed.

### *2.5. Analysis and Consensus*

Rated round two responses were recoded into three levels of agreement: 0–4 (low consensus), 5–7 (medium consensus), and 8–10 (high consensus). Only statements classified as high consensus were analyzed. The percentage of high consensus, mean values and standard deviations were calculated. The high consensus statements, with a percentage of ≥ 65%, a mean value of > 8.0 points and a standard deviation of < 2.5 were finally considered as the final conclusion of the Delphi method. Data analysis was performed using the computer package IBM SPSS Statistics version 24 (SPSS, Inc., Chicago, IL, USA).

### **3. Results**

As mentioned above, twenty introductory letters were sent (five from each cluster). Of these, eighteen respondents fully completed both rounds (90%). Demographic and educational characteristics of the panel members who responded to all rounds are presented in Table 1. Ten were female and their ages ranged from 33 to 61 years old (mean = 46.61, SD = 9.84). Experts came from every area of expertise equally: registered nurses (*n* = 2), management nurse positions (*n* = 2), lecturers or professors at the university (*n* = 2) and lecturers or professors in management positions (*n* = 2). Almost all of the participants had reached the PhD level (75%).


**Table 1.** Characteristics of the study sample (panelists).

Abbreviations: SD = standard deviation; EHEA = European higher education area; RN = registered nurse; MSc = Master of Science; PhD = doctorate.

High-consensus statements that reached the inclusion criteria are presented in Table 2 following a double classification: on one hand, the structure of a SWOT matrix; on the other hand, the main categories created ad hoc and the items. The items comprise a broad spectrum of nursing research topics, from the nursing environment and profession to support from healthcare providers necessary to develop research in nursing.

The strengths highlighted by the experts revolve around three dimensions or categories: academic level achieved, health administration and support from health administration. The most important ideas were the possibility of reaching the PhD level, the possibility of receiving continuous training in research methodology, and access to scientific knowledge through the Internet. These strengths could be reinforced with the following opportunities: the privileged position of nursing to perform clinical research in all areas of health and care levels, the possibility of economic recognition with the PhD level, the creation of specific clinical research units in nursing in the health services, and giving visibility to nurses as researchers.

The weaknesses identified are related to nursing environment, support for research from health administration and the nursing profession: the lack of Spanish nursing journals in which to publish the research results, the lack of funding in nursing care research, and the lack of connection between healthcare institutions and the university. Threats are also related to health administration and the nursing profession. Firstly, "Care research is considered an extra task that must be performed outside the workday" (Participant 9983H). Secondly, the lack of a research mindset among nursing professionals is explained as "There is no culture of research within the profession" (Participant 9990Q). Thirdly, panelists also point out that "The colleagues themselves make it difficult for professionals with research concerns" (Participants 9990Q, 9989P, 9999Z, 9986L).

Finally, a threat related to the historical identification of nursing as a delegate and subordinate profession to physicians with little leadership capacity is detailed as follows: "Become aware that nursing has its own field of knowledge and that it is not subordinate to other sciences such as medicine" (Participant 9997X), "It is not recognized that the nurse can investigate, and being considered as a profession by organizations" (participant 9998Y), and "The persistence of a delegated, subordinate self-image, along with the low ambition of professionals" (9993T).

The rest of the statements that did not reach the minimum consensus required are included in the Supplementary Table S1, as they can help to provide a full picture of the nursing situation in Spain.


**Table 2.** High-consensus statements after round two.

*Int. J. Environ. Res. Public Health* **2020**, *17*, 3224

### **4. Discussion**

The aim of this study was to explore the situation of nursing research in Spain perceived by Spanish experts. To our knowledge, this study is the first to highlight the barriers and facilitators perceived by nurses concerning nursing research in the Spanish context. When it comes to reaching consensus, sharing knowledge, being able to make reflective statements without being personally confronted, and obtaining responses from colleagues in the panel are described as some of the advantages of the Delphi method. Previous studies have pointed out that the panel members affect each other and may change their point of view during the rounds [24]. Moreover, the number of rounds is variable, and when this number is increased, it becomes more difficult to achieve high participation levels [30]. Therefore, two rounds were performed in our study in order not to bias the panelists' opinions during the process.

When analyzing the international context, some common areas appeared as difficulties for nursing research: lack of time during the workday, language difficulties, and lack of financial resources [13]. Having access to almost all areas and health care levels offers a wide range of possibilities in nursing research, which was previously stated in other contexts [1]. Our study confirmed, as in the Swedish context, that an element in favor of nursing research has been the development of doctoral education programs within nursing science, which was made possible by the increase in the number of registered nurses that have the PhD degree. Certainly, nursing research has increased in both quantity and complexity, according to a recent scoping review that identified four global research priorities: nursing theory development, methodology of nursing research, expertise in advanced nursing and professional nursing practice [17].

While, in a study involving seven countries, it was noted as a concern that research in nursing science may be compromised due to the primary supervision of nursing doctoral students by non-nurse supervisors [10], in our context it does not appear as a threat with a sufficient degree of consensus, although this phenomenon does exist. Nevertheless, it has been recently pointed out that nursing as a discipline is rather young and the theoretical development of nursing knowledge is even more recent [17]. The main difficulty in this field is the lack of connection between the healthcare institutions and the university. Creating nursing research units in healthcare institutions and achieving economic recognition of nurses with the PhD level are considered imperative to increase nursing research.

Previous studies carried out in Spain indicated as main barriers the lack of time during the workday to implement new ideas, that nurses do not perceive as relevant the results of the research for its application in clinical practice and the lack of collaboration of physicians for the implementation of nursing research [31]. Even though they do not coincide exactly with the items that have been proposed in our study, conceptual similarities are found, so that our panelists point out that there is no research mindset among nursing professionals. The lack of collaboration with the medical group was also indicated in round two of our study, but it did not reach a sufficient degree of consensus to be included in the final items. Finally, while, in the first study in Spain, a lack of training in research methodology was pointed out as a weakness [14], our study shows that this difficulty seems to have been overcome because panelists identified it as a strength. In this regard, North American nurses in management positions have recently assured, on the one hand, that they are not prepared with the essential skills to succeed so that training and education are essential. On the other hand, they pointed out that most healthcare institutions have prioritized workflow and productivity over research, which does not favor nursing research [32]. These aspects have been stated in our study.

Our study shows that there is still a self-image as a delegate, subordinate profession with little leadership capacity. This situation is specific to the Spanish context, but it has also been confirmed in other contexts [13,28]. This situation is explained by the historical trajectory of the nursing profession in Spain, given that the profession was conceived as an auxiliary of physicians [33]. Until the transformation from polytechnics to university colleges since 1977, nursing did not become an autonomous profession [34]. Certain factors have previously been stated to enhance nurses' leadership skills: gaining experience in policy development, having role models and incorporating leadership skills in bachelors' curricula [28]. Our study shows that academic positions to represent nursing voices

are considered a strength in our country, but nothing is mentioned about achieving management or health policy positions.

### *Limitations*

Our study has several limitations that should be acknowledged. First, this method is not a replacement for rigorous scientific reviews of published reports or for original research. Second, the sample size was small, and this may be considered as a limitation in this study. Nonetheless, it has been stated that a sample of 20–50 experts is recommended for surveys of expert opinions [35]. This type of sampling is particularly useful if the target population from which experts may be drawn is not clearly defined, or if there is great variation in the domain or phenomenon to be studied [36]. In any case, the level of agreement must be set by the researcher prior to implementation; in our case, only high-level consensus and a percentage agreement of > 65% were analyzed. Third, not exploring disagreement or marginalizing dissenting voices may also generate artificial consensus [36]. Fourth, the existence of consensus from a Delphi process does not mean that the correct answer has been found [25], but that a collegiate response has been obtained among the main representatives of the area of knowledge [1], and this response represents an opinion in the instant object of the study; therefore, it may vary over time [24]. Fifth, the sample was selected on purpose, as per the researchers' knowledge of the contribution that the expert panelists could make to the study. This may have resulted in some relevant nurse leaders being excluded.

### **5. Conclusions**

Our study allows us to conclude that the main strengths for nursing research in Spain highlighted by experts were the access and development of PhD programs, as well as the privileged position of nursing in all clinical settings. Elements that could enhance the achievement of leadership in research according to the experts were the creation of nursing research units in hospitals, the economic recognition of nurses with the PhD level, and considering research work as part of the daily tasks of the clinical nurse. Despite the elapsed time, the ideas of being subordinated to physicians and having little leadership capacity apparently remain in nurses' ways of thinking. Experts pointed out that it is necessary to work on the connection between the universities and the healthcare institutions, as well as on raising awareness among professionals in the clinical field about the need for teamwork to achieve leadership in care research. Given that the findings of a Delphi group represent expert opinion rather than indisputable fact, further inquiry to validate the findings and to develop an international panel of experts from different contexts may be important.

**Supplementary Materials:** The following are available online at http://www.mdpi.com/1660-4601/17/9/3224/s1, Table S1: Rest of the statements after round two (Low and medium-consensus statements).

**Author Contributions:** Conceptualization, A.G.-G. and A.D.-F.; Data curation, A.G.-G. and M.S.-M.; Formal analysis, A.G.-G., A.D.-F., N.M.-E. and R.M.-G.; Funding acquisition, A.G.-G.; Investigation, A.G.-G., A.D.-F. and M.S.-M.; Methodology, A.G.-G. and A.D.-F.; Project administration, M.S.-M.; Resources, N.M.-E., D.P.P.-C. and R.M.-G.; Software, M.S.-M.; Supervision, A.G.-G.; Validation, N.M.-E., D.P.P.-C. and R.M.-G.; Visualization, A.G.-G. and A.D.-F.; Writing—original draft, A.G.-G., A.D.-F., N.M.-E. and M.S.-M.; Writing—review & editing, A.G.-G., A.D.-F., N.M.-E., D.P.P.-C., R.M.-G. and M.S.-M.. All authors have read and agreed to the published version of the manuscript.

**Funding:** The Research group "Research in Health and Social Sciences" from the Universidad de Castilla-La Mancha (GI20153025) funded this research.

**Acknowledgments:** The authors express their gratitude to the panel members who voluntarily participated in the study.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*

### *Article* **Nurse Manager Core Competencies: A Proposal in the Spanish Health System**

**Alberto González García 1 , Arrate Pinto-Carral 2,\* , Jesús Sanz Villorejo <sup>3</sup> and Pilar Marqués-Sánchez <sup>4</sup>**


Received: 27 March 2020; Accepted: 30 April 2020; Published: 2 May 2020

**Abstract:** Nurses who are capable of developing their competencies appropriately in the field of management are considered fundamental to the sustainability and improvement of health outcomes. These core competencies are the critical competencies to be developed in specific areas. There are different core competencies for nurse managers, but none in the Spanish health system. The objective of this research is to identify the core competencies needed for nurse managers in the Spanish health system. The research was carried out using the Delphi method to reach a consensus on the core competencies and a Principal Component Analysis (PCA) to determine construct validity, reducing the dimensionality of a dataset by finding the causes of variability in the set and organizing them by importance. A panel of 50 experts in management and healthcare engaged in a four-round Delphi study with Likert scored surveys. We identified eight core competencies from an initial list of 51: decision making, relationship management, communication skills, listening, Leadership, conflict management, ethical principles, collaboration and team management skills. PCA indicated the structural validity of the core competencies by saturation into three components (α Cronbach >0.613): communication, leadership and decision making. The research shows that eight competencies must be developed by the nursing managers in the Spanish health system. Nurse managers can use these core competencies as criteria to develop and plan their professional career. These core competencies can serve as a guideline for the design of nurse managers' development programs in Spain.

**Keywords:** nurse manager; competence; core competencies; governance; leadership

### **1. Introduction**

Economic and social changes have led to an adaptation of healthcare management at all levels and a change in the way in which services are provided [1–6]. The relationship between the economy and sustainability should be causes that make it necessary to develop management competencies with a high level of development, because these competencies are related to higher performance and outcomes [7–10]. To address these changes, nurses need to be part of the core of healthcare [2,4,11,12]. This claim is justified because the nurse is a professional with a high degree of leadership in many healthcare processes [13], because of their closeness to patients, families and the community [14]. Multiple research programs are led by nurses, including oncology, mental health, patient safety, palliative care and childcare, among others, which shows the importance of the nurse in the healthcare system [15–19]. For this reason, the participation of the nurse in the governance of healthcare organizations is recognized as fundamental, both for health outcomes and the sustainability of the health system [20–23].

The American Institute of Medicine, in its report entitled "The future of nursing: leading change in health", already identified nursing in 2010 as a key player in critical decision making and in the transformation of healthcare [24]. In the same way, Weber et al. [25] and McClaringan et al. [20] express themselves by stating that nursing is fundamental to the implementation of shared governance, because their commitment and participation is essential for the sustainability and improvement of health. Panayotou et al. [26] emphasizes nursing within strategic plans, so that their key actions are focused on the creation of a culture of good practice. Brooks-Cleator et al. [27], in his studies on transculturality and governance, focus on the importance of the nurse in establishing a culture of safety. The involvement of nurses in social action committees has achieved a great impact on the everyday problems of people [28], highlighting the importance of their participation in decision making [29]. When the nurse is involved in the different parts of the healthcare process (management and nursing care), better results are achieved [30], communication is enhanced, together with collaboration between the different professional groups, innovation, organizational commitment and retention of staff [23].

Nurse leaders and nurse manager are different roles, although there is a natural overlap of the required competencies [1,10,31]. To develop the role of the nurse in the governance of healthcare organizations, the Global Nursing Leadership Institute (GNLI) in the actions of Nursing Now (2020) has developed a nurse preparation program designed to promote leaders for change, focused on new policies to improve the health of the population [18,32]. Thus, to identify, mentor and train nurse leaders, the management competencies are an essential resource [31]. Furthermore, for the integration of nurses at different levels of organizational management and governance, the nurse should develop management competencies that go beyond the scope of nursing [33–35].

The nurse manager is responsible for planning and managing resources, organizing nursing care, supporting teamwork, evaluating the services provided, and contributing to the achievement of optimal results for the both the organization and the patients [36,37]. Based on the literature review, it is necessary to increase the knowledge of the role of the nurse manager [36,38–41], because the necessary competencies are often not clearly defined [35,42], which would explain this lack of conceptualization of the nurse manager's role. This same absence is evident in the Spanish context since there are no core competencies for carrying out management functions.

Core competencies are the collective learning of the organization, especially with regard to skills related to the generation of a product or service, so that all necessary knowledge and technologies are integrated [43,44]. The core competencies in nursing management are associated with the success of the healthcare organization [45]. Therefore, the core competencies for nurse managers are the set of fundamental competencies needed to ensure their work effectiveness [46]. There are three functional roles within nursing management, the operational nurse manager (performs his or her function at unit level), the logistic nurse manager (performs his or her function at the department level), and the top nurse manager (performs his or her function at the organizational level); all of them should develop the core competencies to help improve the quality of healthcare. [46].

Hence, the main objective of this study is to propose the core competencies to be developed by the nurse manager in the Spanish health system. To achieve this objective, the following specific objectives were set:


This paper is laid out as follows: first, the current state of knowledge about the nurse manager is described. The second part explains the research methods. Next, the results are presented and interpreted. Finally, the paper includes a discussion and conclusion.

### **2. Materials and Methods**

### *2.1. Review Literature*

Based on a scoping literature review during 2018-19 to identify existing competencies related to nurse managers, electronic databases were used (Web of Science, Scopus, PubMed and CINAHL) to conduct the search, identifying 56 competencies for nurse managers. Relevant studies were identified, such as that carried out by the American Organization of Nurse Executives (AONE) who established two competency models for nurse managers [47]. In addition, the literature review identified other important research to define competencies—for example, the Chase instrument [48] or the research carried out by Kantanen [42], DeOnna [35] or Pillay [49], among others. The results of this review are the foundation for the execution of the current Delphi study, which assesses the competencies for nurse manager positions.

### *2.2. Delphi Methodology*

The study was carried out through four rounds of the Delphi method. The Delphi method is a method used to obtain a consensus from a group of experts [50], where the overall view will provide more solid information than that offered by a single person on an individual basis, thus reducing the subjectivity [50,51]. The questionnaires were administered through the LimeSurvey online platform. The questionnaires included an instruction form for the expert, the authorization to participate in the research and the instructions. A reminder email was sent every 4 days until a reply was received. After the survey, the researchers selected or excluded the items that received less than 80% agreement among experts.

The objective of the first Delphi round was to reach a consensus among the panel of experts about the core competencies for nurse managers. During the second round, the experts were asked individually if they wished to reconsider their opinions in light of the feedback. In the third round, the experts were asked to provide a consensus about the core competencies at each nurse manager on a functional level. The experts also agreed on the training required for each level of competence (expert, very competent, competent, novice advanced and novice). The fourth round allowed experts to reconsider their opinions in view of the feedback from the third round.

### 2.2.1. Consensus

In any Delphi study, the definition of consensus should be set a priori. Thus, for this research, we defined the consensus in three ways: (I) if at least 80% of the experts agreed with the competencies, responding "agree" or "complete agreement" in the questionnaires; (II) if at least 80% of the experts agreed with the degree of development of the competencies; (III) if at least 80% of the experts agreed with the type of training required. Where an agreement was not reached, items were deleted for the next Delphi round.

### 2.2.2. Participants

In this study, we decided to invite experts from two categories and twelve groups: experts in health management (Table 1) and experts in the health environment (Table 1), because experts in these two categories have valuable knowledge on nursing management.


**Table 1.** Socio-demographic data from the panel of experts.

Source: own elaboration.

### 2.2.3. Variables

The variables of the study were:


### 2.2.4. The Delphi Questionnaires

Two questionnaires were developed ad hoc as measuring instruments.


agreement or disagreement with each competency according to a one to five Likert scale (1 = novice, 5 = expert), and the type of training required to develop the competencies, according to a one to six Likert scale (1 = University Extension Diploma, 2 = Continuing education, 3 = University Expert, 4 = University specialization diploma, 5 = master's degree, 6 = Ph.D.) was recorded.

### 2.2.5. Level of Development

For this research, the term "level of development" was used to refer to the level of deepening in each competency that the nurse manager should acquire in each of the functional levels, thus the level of development would be:


### 2.2.6. Validity and Reliability

The validity and reliability of the questionnaires was carried out with a group of 12 people selected on the basis of the same criteria used for the panel of experts. The reliability of the questionnaires was ensured by carrying out a Cronbach's Alpha Coefficient analysis. The content validity was estimated through expert judgement, which analyzed errors and ambiguities in the formulation of the questions, excess items, proposals for improvement, suggestions for the style of the surveys.

### *2.3. Principal Component Analysis*

The Principal Component Analysis (PCA) is a data transformation technique. The aim of the method is to reduce the dimensionality of multivariate data, while preserving as much of the relevant information as possible [52]. The factor analyses were carried out with respect to the theory of Thurstone [53,54] (3 phases): first, the assessment of the adequacy of the data for factorial analysis, second, the extraction of factors, and finally the rotation and interpretation of factors.

For determining the suitability of the data for factorial analysis, we used the Kaiser–Meyer–Olkin (KMO) test. The next step was the extraction of factors, using Kaiser's criteria, which makes the decision based on an eigenvalue greater than one [55], and a scree plot, which is a graphical representation of the eigenvalues. This graph helps to find the inflexion point and the number of factors above this point that should be retained [56]. Finally, we proceeded with the rotation and interpretation of the factors, through the varimax rotation method and Kaiser standardization, to achieve a structure as simple as possible that was easy to interpret [57].

### **3. Results**

### *3.1. Demographics of the Expert Panel*

A total of 50 experts consented to participate and took part in the Delphi study. Table 1 lists the demographic characteristics of the complete expert panel. The response rate for all of the Delphi rounds was 100%.

### *3.2. Delphi Study*

During the first and second Delphi rounds, 51 competencies were agreed by consensus (more than 80%) from the proposed list. In round 1, the percentage of "total agreement" was 100% ("agreed" or "complete agreement") with the competencies decision making, communication skills, listening and conflict management. In this round, more than 80% of the experts were in "total agreement" with

eight competencies (Table·2): decision making, communication skills, listening, leadership, conflict management, ethical principles, collaboration and team management skills.

Experts in round 2 were provided with individual feedback from the round 1 survey. This feedback included the complete expert panel responses. Participants were asked if they agreed or disagreed with the statements that were made in the previous round. From round 2, it appears that the experts showed a "complete agreement" with a percentage equal to 100% in the competencies identified as the core competencies (Table 2). In round 2, the competencies with less than an 80% consensus were eliminated.


**Table 2.** Core of competencies.

Source: own elaboration.

During the third and fourth Delphi rounds, the eight competencies from the core competencies were shown to be necessary for the three levels of nurse manager existing in Spain (operations, logistics and top management), differing in the level of development of the competencies at each level of management ("Expert", "very competent" and "competent"). The panel of experts in round 3 were asked about the level of development of each competency to reach a consensus. The experts in round 4 were again provided with individual feedback from round 3, and asked to indicate their agreement with statements that were made by participants in the previous round. The final consensus is shown in Table 3.

**Table 3.** Development of core competencies at each level of nurse manager.


Source: own elaboration.

During the third round, the experts were asked to indicate their opinion about the appropriate training to reach the right level of competency. In round 4, experts were again provided with individualized feedback from the previous round. The final consensus is shown in Table 4.


**Table 4.** Training required by competency level.

### *3.3. Principal Component Analysis*

The data were suitable for factoring as the correlation matrix showed a predominance of meaningful results (*p* < 0.05), Bartlett's test was significant (*p* < 0.001) and KMO value was 0.505. The integration of competency listening into the competency communication skills was appropriate for factoring (as shown in Table 5).


**Table 5.** Principal Component Analysis (PCA) of core competencies.

Source: own elaboration. Caption: communication (CP), leadership (CP2), decision making (CP3).

The extraction of factors showed three factors that explained 68.67% of the total accumulated variance. The varimax rotation method yielded a three-factor solution: communication, leadership and decision making (Table 5). The observed convergence between the Kaiser criteria and the scree plot adds certainty to the results. The reliability of the core competencies showed a Cronbach's alpha value of 0.613, indicating a satisfactory result. (Table 5).

### **4. Discussion**

This paper reports on the findings of the core competencies to be developed by the nurse manager in the Spanish health system. Decision making, relationship management, communication skills, listening, leadership, conflict management, ethical principles, collaboration and team management skills were seen as the core competencies for nurse managers. These findings are consistent with the findings from previous studies [47,51,52]. Kantanen et al. [42] emphasizes competency in decision making as a critical competency. McCarthy [58] highlights core competencies that are aligned with our research in communication, relationship management, ethical values and decision making. Our research is also aligned with Pillay [59] and with Gunawan [60], when he described relationship management, conflict management and collaboration and team management as basic competencies.

To emphasize the strength of the core competencies identified in this research, we should say that this were also identified through a scoping review of the literature, with the exception of the listening skills and ethical principles, which were not found among the most frequent results in the review. It should be noted that the frequency of citation in the selected articles was used as a criterion for identifying the core competencies in the literature review.

This study identified that all the core competencies are needed independent of the functional level of nurse managers (executive management, logistics and operational management). Although each functional level requires different levels of competency development to be reached. There was a consensus between the experts in Delphi rounds 3 and 4. These findings are consistent with findings from previous studies (e.g., [47,58]). McCarthy et al. [58] highlighted that core competencies should be common to all three levels of management at different degrees of development. The AONE [61] has shown shared competencies in their different models ("Nurse Manager Competency", "Nurse Executive Competencies" and "Nurse Executive Competencies: CNE system"), and in the Nurse Executive Competency Assessment Tool, which differentiates the degree of development of each competency. In another sense, the AONE also defined non-shared competencies in their models.

With regard to the development of competencies, an agreement was reached in Delphi rounds 3 and 4. The experts agreed that competencies should be developed at "competent" (this was considered to have been reached when there is a strong demonstration of competency), "very competent" (level reached when there is a significant demonstration of competency) and "expert" level (level reached when it demonstrates the behavior of the competency model). This proposal is in agreement with AONE, who use the levels competent, proficient and expert for the development of competencies, emphasizing how these levels are reached through master's degree studies or a Ph.D. [62,63]. In contrast, in other studies such as "Nurse manager competencies", the focus is on the degree to which the competencies contribute to the nurse manager's work (minimally, moderately, significantly and essentially) [48]. Furthermore, the results of the current study emphasize the need for a high level of competence development, in the same way that Crawford et al. [64] demonstrated by indicating how executive practice would require a high degree of specialization and a specific development of competencies.

During Delphi rounds 3 and 4, the expert panel achieved a consensus about the training to be developed by the nurse manager on the three competency levels ("expert", "very competent" and "competent"). The "competent" level is reached through continuing education, University Expert and University specialization diploma. With regard to the "very competent" level, the consensus was reached with University expert, University specialization diploma or master's degree. Finally, the "expert" level is reached through master's and Ph.D. studies. We should keep in mind how work experience and education significantly influence the development of competencies of nurse managers [65]. However, experience as a nurse manager does not prepare them for the wide range of skills needed, requiring specialized training and work experience in concrete situations [33,66]. Learning experientially as a nurse manager should be accompanied by prior planning and close mentoring [67]. Previous studies show that the quality and level of training are responsible for orienting nurse managers towards good governance and the acquisition of the global vision of the organization [33,68,69]. Furthermore, the results of the current study emphasize how it is possible to appreciate differences between nurse managers who have completed advanced management programs with respect to others who have not participated in this type of training program, adding evidence to previous studies [68,70]. We share the recommendations given by the Joint Commission for Accreditation of Healthcare Organizations regarding the development of different career levels for nurses according to their level of education, training and experience [71]. In addition, and just like Fralic [72] affirmed, our results suggest that the training received by nurse managers would be one of the key aspects, because they are responsible for managing the area with the largest number of people, to make decisions about resource management and other areas such as quality of care, patient safety, research, training, expenditure or investment. The present study, along with other previous studies such as the research carried out by Herrin et al. [73], support that the master's degree

training allows the nurse manager to be able to carry out adequate decision making, as well as for the effective management of health processes. In the same way, Rizani et al. [74] point out that the average competence of nurses is higher when they have developed advanced studies (master's degree or Ph.D.), increasing with time their level of competency to a higher degree than those nurses who have not developed advanced training.

The PCA verified the core competencies by defining three principal components named communication (communication skills, relationship management, conflict management), leadership (leadership and team management skills) and decision making (decision making and ethical principles), which would therefore constitute the competency factors to develop the role of a nurse manager in Spain (Table 6). The strength of the eigenvalue confirms the importance of the relationship between decision making and ethical principles [75], the need for strong leadership in working groups [76] and communication as a fundamental element in conflict resolution [77]. By comparing the core competencies emerging from our research with the most relevant international studies into core competencies for nurse managers, we would find a shared factor with communication, which should indeed be presented as a shared factor [25,78,79].



Source: own elaboration.

The communication ability that would be expected from the nurse manager should include the ability to convey critical thinking and generate reflection in nurse teams prior to action [36]. In the same way, it should, for example, facilitate conflict resolution and shared decision making, as well as creation, participation and team management [80]. The differences that would arise between all the core competencies could be related to the different health contexts in which management practice takes place [58].

The purpose of this study was to determine the core competencies for each functional level of nursing management by expert consensus. Our research contributes strong and important evidence to the nursing management field. Firstly, we provide a baseline of competencies for nurses who intend to carry out functions as nurse managers. Secondly, our study is also useful as a tool for evaluating and detecting areas for improvement for nurse managers. Finally, the core competencies should be useful for planning the professional development of nurse managers.

With regard to the limitations of this research, we should mention the different healthcare contexts from which the body of research knowledge is derived. Nursing management has specific characteristics for each of these contexts.

### **5. Conclusions**

This study found core competencies for nurse managers in Spain. The successful nurse manager should develop all these competencies (as relevant to their practice) in today's rapidly evolving healthcare system. In conclusion, this study yielded a consensus on eight core competencies for nurse managers in Spain: decision making, relationship management, communication skills, listening, leadership, conflict management, ethical principles, collaboration and team management skills, oriented towards leadership and good governance of health organizations, and on the basis of the social responsibility of health professionals. The nurse manager is responsible for the largest area of a healthcare organization, managing large budgets and large numbers of nurses. Therefore, a nurse should not be promoted to the role of a nurse manager without advanced management training.

Our research shows the precise level of development of each competency for the different functional levels of nurse manager. The nurse manager at any functional level should develop these core competencies before being promoted to other roles as a nurse manager.

Any nurse who wishes to develop his or her professional career as a nurse manager should first develop the core competencies shown here.

Moreover, our research shows the necessary education required to acquire the competency development necessary for each different nursing management role. Both nurses who want to be promoted to nurse managers and current nurse managers should follow the educational programs shown in order to adapt their knowledge to the requirements of the role.

These core competencies may have implications for practice, organizational policy, and education related to nursing management. The proposed core competencies may contribute to nurse manager role design, selection processes, and nurse manager curriculum design for traditional academic institutions and organizational continued professional development programs. Further understanding of core competencies is likely to inform interventions, which may improve nurses' work environment, patient care, patient safety and organizational outcomes.

The following research should develop the characteristics corresponding to each of these competencies and training situations.

**Author Contributions:** Conceptualization, A.G.G.; A.P.-C.; P.M.-S.; and J.S.V.; methodology, A.P.-C.; A.G.G.; validation, M.P.-S.; formal analysis, M.P.-S.; A.P.-C.; investigation, A.G.G. and P.M.-S.; resources, J.S.V.; and writing—original draft preparation, A.G.G. and P.M.-S.; writing—review and editing, A.G.G.; A.P.-C.; P.M.-S.; J.S.V. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **Appendix A. Competencies Needed for Nurse Managers**

Please select the appropriate answer for each concept:


#### **Table A1.** List of competencies.


**Table A1.** *Cont.*

Caption: 1 = Complete disagreement; 2 = Disagreement; 3 = No disagreement/No agreement; 4 = Agreement 5 = Complete agreement.

### **Appendix B. Level of Competency Development for Nurse Managers**

In this section, you should mark which functional level(s) each competency corresponds to, taking into account that the competency may be necessary for all three levels.

You should also indicate the level of development of this competence.


**Table A2.** Development of competencies

Indicate to which degree of training each competence level should be developed:



Caption: University Extension Diploma (U. Ext D); Continuing education (C. Edu); University Expert (U. Exp); University specialization diploma (U. Spec. D.); Master's degree (Master); Ph.D (Ph.D).

### **References**


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International Journal of *Environmental Research and Public Health*
