Austrian Nurses’ Positive Opinions on Geriatric Care and Their Ideas for Tackling Challenges in Caring for the Ageing Population– A Modified Focus Group Study in Long-Term Care

Austrian Nurses’ Positive Opinions on Geriatric Care and Their Ideas for Tackling Challenges in Caring for the Ageing Population– A Modified Focus Group Study in Long-Term Care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Austrian Nurses’ Positive Opinions on Geriatric Care and Their Ideas for Tackling Challenges in Caring for the Ageing Population– A Modified Focus Group Study in Long-Term Care Lena Maria LAMPERSBERGER, Eva POCK, Christa LOHRMANN, Franziska GROSSSCHÄDL This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6342610/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Sep, 2025 Read the published version in BMC Nursing → Version 1 posted 4 You are reading this latest preprint version Abstract Background: As the demand for long-term care increases due to a global ageing population, ensuring continuous and high-quality geriatric nursing is crucial. However, geriatric nursing faces challenges such as workforce shortages, high workload, and high emotional demand, which can impact quality of care, job satisfaction, and intentions to leave the profession. Little is known about nurses’ opinions on geriatric nursing and their ideas for addressing challenges in caring for the ageing population. This study aims to explore what nurses in Austria value about working in geriatric nursing and their ideas on addressing challenges in geriatric nursing. Methods: A descriptive qualitative study was conducted using a modified focus group approach that included freelisting interviews and the nominal group technique. Two focus groups in the form of workshops were held in 2025 with 12 nurses working in long-term care in Austria. The freelisting data were analysed using salience analysis, while the ranked ideas generated in the nominal group technique were analysed using Van Breda’s method of ranking. Descriptive statistics were used to summarise participant demographics. Results: Nurses valued the appreciation they received from older persons they care for and colleagues, the opportunity to work within the family and related persons of older persons, and their ability to provide individualized and person-centred care. A skilled geriatric nurse was described as having empathy, sensitivity, and broad expertise in health care. The three highest-ranked ideas for strengthening geriatric nursing were (1) Promoting and strengthening older persons’ self-care abilities (e.g. providing holistic, individualised care), (2) Coordinate care for the older persons between services, and (3) Promoting and strengthening the team. Conclusions: These findings suggest that strengthening geriatric nursing requires structural improvements, enhanced collaboration across healthcare sectors, and recognition of nurses’ competencies. Implementing a supportive work environment, optimising skill- and grade-mix approaches, and listening to nurse’s expert insights may contribute to sustainable and high-quality long-term care for the aging population. Future research should consider a co-research design to plan target group and setting specific interventions in geriatric nursing based on nurses' ideas. Long-term care geriatric nursing ageing population nominal group technique freelisting interviews Figures Figure 1 Background ‘‘ Caring for older people can be challenging, beautiful, and rewarding’ […] (QN 103, 34 years, long-term care) ’ [1, p. 8] was written by a nurse about the care of older people in a study assessing nurses’ experiences and opinions on caring for older people [1]. Although this quote reflects a positive opinion about geriatric nursing, an international body of research shows that the career choice of geriatric nursing is not a popular one among nursing students and nurses [2-4].The global nursing community is currently facing a shortage in personnel [5, 6], a situation compounded also by the demographic shift towards an ageing population [7]. However, it is predicted that in future there will be a greater demand for well-trained and specialised geriatric nurses, in order to ensure that the quality of nursing care for older people with a need for care due to higher rates of care dependency and care needs [6, 8, 9]. When a person’s need for care arises, holistic nursing interventions must be taken in an equipped care system to ensure that people in need of care receive appropriate and timely care to meet their physical, mental, social, and spiritual needs. Holistic nursing interventions focus on these physical, psychological, sociological, and spiritual needs of a person rather than on their disease or care need [10]. The need for holistic care of the ageing population is often met through long-term care [11]. The WHO (World Health Organization) defines long-term care as activities ‘ to ensure that people with or at risk of a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity’ [11, p. 7]. Long-term care aims to provide care for people who need assistance with activities of daily living to maintain functional ability [11]. It focuses on the health, personal care, and social needs of people in care [11]. In the field of long-term care, the demographic of service users is mostly composed of older people where frequently assistance is needed with activities of daily living [12, 13]. This care can be provided in a variety of settings, including the person's home, the community, or residential long-term care facilities [11]. Depending on the level of care needed, older people prefer to stay in their own homes or in familiar surroundings if they have moderate care needs, but prefer residential care if they have greater care needs [14]. To ensure that long-term care is sufficient and sustainable, sufficient numbers of well-trained nurses are needed in this setting to provide appropriate, high-quality care in the right setting for each individual [7]. Nursing professionals, including qualified nurses and nursing assistants make up the majority of the long-term care workforce besides informal caregivers [5, 6]. According to Eurofound [6], it is concerning that in Austria three out of four people working in acute or long-term care have considered leaving their position as it is estimated that in future 5-10 % more qualified nurses will be needed in long-term care. Working conditions (physical workload, mental workload, and time pressure) have an impact on the willingness to continue working in long-term care [15]. Looking at the working conditions prevalent in European long-term care, there are several points of criticism voiced by nurses such as low pay, low quality of working time (e.g., part-time work, shift work, and working at short notice), high emotional demands [6], and a high risk of experiencing forms of violence (e.g., verbal or sexual harassment or physical violence) [6, 16]. In a study conducted among Austrian nurses, it was found that working conditions (e.g. lack of resources to provide quality care, consequences for physical, and mental health) were more often criticised than the geriatric nursing profession itself [1]. These factors increase the exposure of nurses to the risks of impaired physical, and mental health, occupational accidents, cardiovascular diseases, burn-out, depression, injuries, lower job satisfaction, and higher employee turnover rates [6, 16, 17]. Furthermore, due to these factors, nurses have the feeling of not being able to provide sufficient care to improve the quality of life of those being cared for as they lack the time to, for example [18]. In a Swedish study, nurses perceived geriatric nursing positively as holistic and respectful work where they could build long-term relationships with the persons they care for and their families and provide individualized and person-centred care [19]. These positive opinions of nurses on geriatric nursing influence their intentions to embark on a career in geriatric nursing or to stay in the profession [3, 20-22], which might be explained by the Theory of Reasoned Action [23]. Fishbein and Ajzen’s [23] Theory of Reasoned Action shows that opinions are formed by experiences, interactions with a person, or by information from an outside source. By forming these opinions, one links attributes to an object (e.g. geriatric nursing) which are evaluated (positively, negatively, or neutrally) and lead to the formation of attitudes (e.g. towards geriatric nursing). The sum of opinions and attitudes towards something then influences one’s intention to perform a specific behaviour (e.g. not considering a career in geriatric nursing, leaving the profession) [23]. Since Covid 19, the pandemic has taken a toll on health care and on long-term care and the nursing shortage has intensified [24]. Nurses' opinions about long-term care may now be more critical and negative, as the work has become more demanding and nurses criticised the work environment repeatedly meaning that their interactions and experiences with geriatric nursing is more strained [1, 18]. In the international literature, there is a lack of recent research on long-term care nurses' perceptions of long-term care and on what strengths they see in their work. Furthermore, the voice of nurses regarding what they need to provide care in a way that they, as experts, consider to be of high quality is rarely heard [1, 18]. In the light of a global ageing population and nursing staff shortages, this knowledge might be needed in order to plan target group and setting specific interventions supporting geriatric care in a way that is meaningful and needed by those who are affected [24]. Therefore, in this study we aim to investigate nurses’ priorities with regard to two research questions: What do nurses value about working in geriatric care? What are nurses’ ideas on how to address challenges in geriatric care? Methods This study is a descriptive qualitative study using a modified focus group method including freelisting interviews [25] and the nominal group technique [26]. These methods are especially suitable for target groups with a high workload and lack of time resources [25, 27]. We therefore deemed these methods suitable for focus groups including nurses who work in a stressful and understaffed environment [24]. In addition, freelisting interviews can reveal the priorities and attitudes of a culture [25], and the nominal group technique is particularly useful for focus groups where the goal is to generate ideas and find consensus on their priorities [26, 27]. The Standards for Reporting Qualitative Research (SRQR) checklist was used to guide the reporting of this study [28]. Setting and Participants In this study, long-term care is defined as care provided by nurses in a long-term care facility, at home, or in the community, including nursing homes, home care, and community care. Nurses working in long-term care in southern Austria were invited to join the focus groups planned as a workshop and entitled ‘What do you wish for? Ideas for strengthening geriatric nursing’. Nurses with a diploma, specialised nurses (i.e. with a Bachelor degree or a diploma), or nurses without a diploma who actively worked in geriatric nursing were invited to participate. In Austria, nurses earn either a Bachelor degree or a diploma after completing a three-year training programme. After graduating, they can specialise in areas such as intensive or palliative care by completing a one-year university course. Nurses without a diploma can specialise by attending training lasting one or two years. Since all these nursing professions work in geriatric nursing [29], they were included in this study. Sampling Two sampling methods were used to recruit participants for this study: (1) convenience sampling and (2) snowball sampling (1). At the beginning of January 2025, an invitation to participate in the workshop and a flyer including information about the workshop were mailed to all residential and home care facilities, to nursing managers in these facilities, and to community nurses in a city in southern Austria and the surrounding area. A list of mail addresses was retrieved from government homepages [30-33]. The nurses were asked to forward the invitation and flyer to their network and to other nurses who might be interested in participating. Reminders were sent out two weeks later. Invitations were sent only to institutions in this particular city and its surrounding areas as the workshop was held at the local Medical University and to ensure short commutes for participants. The flyer was also shared on social media platforms (LinkedIn and Instagram) at the beginning of January 2025 and reposted twice in the following month. The local nursing association and local stakeholder also shared the invitation via their social media channels. Use of social media platforms was chosen to increase the possibility of reaching interested nurses who might not have received an invitation. (2) Nurses in the researchers’ network were asked directly if they wanted to participate, were given a flyer and were asked to bring interested colleagues to the workshop. The aim was to recruit participants for two workshops with 6-10 participants each as according to the literature this is the ideal group size for conducting meaningful discussions [34]. In total, 12 nurses participated in the two workshops. They had a median age of 34.5 years and a median geriatric working experience of 9 years. The demographic and professional characteristics of these participants can be found in Table 1. Table 1 Demographic and professional characteristics of participants (N = 12) Variable Category n Sex Female 10 Male 2 Profession Nurse with a diploma 7 Nurse without a diploma 5 Setting Residential long-term care 7 Home and community care 5 Focus Groups We conducted two focus groups in February 2025. The focus group was designed as a workshop for nurses to work on ideas regarding challenges in geriatric nursing. Two researchers facilitated the workshop, with one (LML) leading the workshop and the other (EP) taking notes, making audio recordings of discussion phases, and preparing data from the freelisting interviews and the nominal group technique for presentation to the participants at the end of the workshop. The workshop consisted of five phases and lasted for three hours: (1) welcoming the participants and collecting demographic data, (2) an icebreaker task to get the participants in the mood for the topic and to create a basis for discussion, (3) two freelisting interview questions to assess positive opinions on geriatric nursing and what qualities they attribute to a skilled geriatric nurse, (4) collecting and prioritising ideas for tackling challenges in geriatric nursing using the nominal group technique, and (5) discussing the results. Figure 1 shows an overview of the five phases of the workshop, which are also described in detail below. At the beginning of the workshop participants were welcomed by the researchers and the researchers and the participants introduced themselves. Each participant was handed a package of materials that included the written informed consent, a questionnaire on demographic data, sheets for freelisting, and sheets for the nominal group technique. Demographic data included sex and age of participants, followed by questions about their work. They were asked about their profession, the setting in which they work, and the number of years they have worked in geriatric nursing. Next, the workshop leader explained the steps included in the workshop and gave a brief overview on what the workshop is about. As an icebreaker, participants thought about how they would complete this sentence: ‘ Geriatric nursing for me is ... ’. They were then asked to share their understanding of geriatric nursing with the group, if they were willing. Two questions were worked on with the freelisting interview technique. The first was ‘ What do you value about your work in geriatric nursing? ’ and the second was ‘ When you think of a colleague whom you consider to be a skilled geriatric nurse, what makes them special? ’. Participants were asked to list anything that came to mind on a prepared sheet. They were given 5 minutes per question. If participants were still listing items after five minutes, they were given more time. Freelist interviews identify items in a cultural domain or emic category and show what is most important or salient to the participants as they tend to list familiar items first [25]. In the nominal group technique phase, the participants focused on one question: ‘ If you could change five things about your current working day, what would they be? ’. The nominal group technique has four stages [26]: (1) The first stage, ‘idea generation,’ consists of each participant writing down ideas individually, one idea per card. In our workshop, participants had to write down five ideas each and were given 10 minutes. (2) The second stage is called 'round robin', where participants say their ideas one by one and stick them on a flipchart. In this stage, the ideas were not discussed or clarified. 15 minutes were allotted for this stage. (3) The third stage was a group discussion of the ideas generated. In this stage, ideas could be clarified, discussed, grouped or further divided until a consensus was reached in the group. In addition, an audio recording was made of the discussion. The workshop leader recorded the agreed ideas and their explanations on a whiteboard. (4) Finally, in the fourth stage, participants voted on their top three ideas and ranked them using a prepared sheet. This stage lasted 5 minutes. At the end of the workshop, the results of the freelisting interviews and the nominal group technique were presented to and discussed with the participants. An audio recording was also made of this discussion. Data Processing and Analysis Like the focus groups, the analysis also consisted of several stages. First, demographic data were analysed using descriptive statistics in Microsoft Excel (Microsoft Office LTSC Profssional Plus 2021) [35]. Notes of the icebreaker task were entered into the software MAXQDA 2020 [36]. Second, freelists were entered by one researcher into Microsoft Excel (Microsoft Office LTSC Profssional Plus 2021) [35]. The participants and two groups were pooled and synonymous items were grouped into one item. This process was checked for accuracy by a second researcher. This resulted in one list per question. A salience analysis was performed on these two lists. This involved calculating the salience of each item on each participant's list. The ranked items were numbered inversely and divided by the total number of items. The composite salience value was then calculated by dividing the sum of salience per item by the number of participants. There are no clear boundaries for what value is considered salient, thus we determined the salience of items according to breaks in the data visualised by bar graphs (see Additional File 1 and Additional File 2) [25]. Third, the nominal group technique was analysed integrating both groups according to the method proposed by Van Breda [37]. The ideas generated were entered into Microsoft Excel [35] spreadsheets and the top five ideas were identified by average scores. Each first-ranked idea received 15 points, second-ranked ideas received 10 points, and third-ranked ideas received 5 points. A content analysis of the generated ideas was then performed in MAXQDA 2020 [36], and overarching themes of ideas were defined. The content analysis was performed by one author and peer reviewed by a second author. Finally, the combined ranks of both groups were calculated by a ‘top 5 score’ that includes only rated ideas, a ‘number score’ that includes the frequency of themes, and an ‘average score’ that standardizes the score of ideas independent of group size. [37]. The audio-recorded discussions were transcribed using NoScribe (version 0.6) [38] and checked for accuracy by one of the researchers. Quotes included in the results have been translated into English by one author and DeepL Translator (Version 24.11.4.14424) [39] and checked by a bilingual English native speaker. Ethical Considerations This study was approved by the Ethics Committee of the Medical University of Graz (EK Number 31–320 ex 18/19). Participants signed a written informed consent and were informed that they could withdraw from the study at any time. Digital data is stored on the university's secure network and written data is stored securely at the university. Only the researchers have access to the data. Rigour To enhance trustworthiness and credibility, the two researchers (LML and EP) that were involved in holding the workshops met beforehand to discuss the workshop guide in detail and to reflect on their possible influence on the process and on participants. To ensure authenticity, both researchers are nurses with a diploma, experienced in the geriatric setting. Following the first workshop, the understandability of methods and questions were evaluated with the participants and discussed by the two researchers. No changes were made. After each workshop, peer debriefing was carried out as the researchers reflected again on possible influences they had on the discussions and on group dynamics. To ensure reliability and validity of the data, member checks were carried out by presenting results of the workshop to the participants at the end of the workshop. The participants had the opportunity to discuss the results, confirm their validity, and to add additional remarks. The data analysis was performed by one author and peer reviewed by a second author. If necessary, discrepancies were discussed until a consensus was reached. Every step of analysis was discussed by the two authors involved in the analysis process [40]. Results The workshops began with nurses reflecting on what geriatric nursing means to them. Overall, it was discussed that a central part of geriatric nursing for them was the complexity and diversity of the field involving caring for people with co-morbidities. In addition, the provision of individualised and holistic care that promotes resources and goes beyond mere care to help shape the daily lives of older people was seen as a core skill of geriatric nursing. It is the nurse who is primarily responsible for the care and well-being of older persons. After this initial icebreaker exercise, the workshop moved on to the freelisting interviews. In response to the question 'What do you value about your work in geriatric nursing' , the most salient item was that nurses experience a lot of gratitude or appreciation for their work, either from their colleagues or from the people they care for. Nurses also have a positive opinion regarding the opportunity to support and challenge the self-care abilities of the older person they care for and the older person themselves. This was followed by the opportunity to work with the older person they care for, their families, and their relatives. All salient items generated by the nurses in relation to valuing geriatric nursing can be found in Table 2 and all generated items can be found in Additional File 1. Table 2 Freelist of salient items of nurses’ positive opinions on geriatric nursing (N = 12) ‘ What do you value about your work in geriatric nursing? ’ Frequency Composite Salience Lots of gratitude/appreciation (persons they care for/colleagues) 9 0.46 Supporting and challenging care needs and older person themself 4 0.26 Working with the family and relatives of older persons 5 0.23 Teamwork/support/help within the team 5 0.22 Wide-ranging/complex field of activity 3 0.21 Providing support and involvement in the everyday life of the older person 4 0.20 Autonomy/taking responsibility 5 0.19 Personalised care planning according to needs/assessment of needs 5 0.19 Communication/listening/talking/laughing/crying together 4 0.18 Enabling years of healthy life/quality of life 3 0.17 Working in a multi-professional team, utilising networks and interprofessional approaches 5 0.17 Working with people 2 0.16 Note: Higher composite salience scores indicate higher salience, composite salience is calculated by numbering the ranks per list per participant inversely and divided by the total number of items per list. The composite salience value is then calculated by dividing the sum of salience per item by the number of participants on a combined list per question [25]. After the second freelisting activity, the nurses collected items in response to the second question: 'When you think of a colleague whom you consider to be a skilled geriatric nurse, what makes them special? ’ The most salient point was that a skilled nurse has a high degree of empathy, sensitivity, and compassion. A skilled nurse also requires expertise and broad knowledge in health care, and takes time for the people in care, even when under stress. All salient items that nurses attribute to a skilled geriatric nurse can be found in Table 3, and all generated items can be found in Additional File 2. Table 3 Freelist of salient items of what nurses consider to be a skilled geriatric nurse (N = 12) ‘ When you think of a colleague whom you consider to be a skilled geriatric nurse, what makes them special? ’ Frequency Composite Salience Has a high degree of empathy/sensitivity/compassion 11 0,65 Has expertise and knowledge in health care 7 0,31 Takes their time (despite stress) 4 0,30 Is very organised/structured/precise 5 0,30 Has several years of professional experience 4 0,26 Has patience/a calm disposition 5 0,23 Listens closely/has an open ear 5 0,22 Is constantly learning, regularly participates in ongoing training 4 0,18 Shares knowledge/guides other employees/helps colleagues 5 0,16 Respects individual wishes 3 0,16 Is caring/has a gentle manner with older persons 2 0,15 Works with foresight, keeps sight of what’s important/able to assess situations 3 0,14 Is motivated 2 0,14 Has a sense of humour 4 0,14 Is reliable 2 0,14 Able to observe and perceive well 2 0,13 Prioritises taking into account the environment of older persons 3 0,13 Can express themself well/ has good communication skills 6 0,13 Note: Higher composite salience scores indicate higher salience, composite salience is calculated by numbering the ranks per list per participant inversely and divided by the total number of items per list. The composite salience value is then calculated by dividing the sum of salience per item by the number of participants on a combined list per question [25]. [Add Table 3 here] After the nurses had discussed positive opinions on geriatric nursing and the attributes they assign to a capable geriatric nurse, the participants used the nominal group technique to develop their own ideas for strengthening geriatric nursing. This was guided by the question ‘ If you could change five things about your current working day, what would they be? ’. After the individual ideas were discussed in the groups and the researchers analysed the themes of the ideas collected and agreed upon, eight themes of ideas emerged (see Table 4). The three ideas that where most important to the participants and therefore ranked higher were (1) ‘Promoting and strengthening older persons’ self-care abilities, (2) ‘Coordinate care for the older persons between services, and (3) ‘Promoting and strengthening the team’. Table 4 Ranking of generated ideas for strengthening geriatric nursing using the analysing method by Van Breda [37] Themes of ideas Top 5 votes Average score Final rank score Promoting and strengthening older persons’ self-care abilities 3 33.75 23 Coordinate care for the older persons between Services 2 30 18.5 Promoting and strengthening the team 2 20 15.5 Strengthening the image and value of geriatric nursing 1 25 14.5 Facilitating holistic prevention 1 40 14.5 Residential long-term care as suitable place for individual old age 1 25 11 Promote focused training and professional development 0 15 6 Promoting equal opportunities for persons in care 0 10 5 Note: Higher final rank scores indicate higher ranking of ideas, the top three ranked themes of ideas are presented in bold. Scores are calculated according to Van Breda [37] Promoting and Strengthening Older Persons’ Self-care abilities Strengthening older persons’ self-care abilities can on the one hand be reached on the part of the older person and on the other on the part of nurses, facilities and structures. To be able to provide care that promotes and strengthens the self-care abilities of older persons, participants discussed that holistic care is needed that is tailored to the older person based on their biography. They suggest that early on, when a need for care first arises, persons in care write down their needs and preferences. A nurse describes that ‘[…] for each activity of daily life, the person should write down how they would like it to be. For example, would they prefer a shower or a bath, warmer water or do they like it a little cooler .’ (HCCN 2.1). Furthermore, on this topic nurses discussed that nursing services in particular are not sufficiently publicly funded, which leads to unequal opportunities for persons in care. They say: ‘At the moment, it depends on whether I can afford it or not. It's about equal opportunities.’ (HCCN 1.3). They propose that home care, family caregivers, community nursing and social interventions should be better funded from public funds. They further discussed that to relieve the burden on family caregivers, it should be possible to receive funding for support provided by nursing professionals for a few hours a day. HCCN 1.3 states the problem: ‘It is often the case that some people need support throughout the day [...] That they cannot provide home care for the entire day [...] That is not actually subsidised at all. You have to pay for it yourself.’ Furthermore, participants discussed that in order to provide holistic care, they need more time with the person they care for, in addition to basic nursing interventions, for individual care, social interventions and preventive interventions. They suggest that more time resources can be made available by reducing bureaucracy and minimizing care planning to essential interventions. NH 2.2 for example proposes that: ‘ I find that many things, especially in care planning, are no longer all that up-to-date such as the housekeeping components, making the bed, for example, [...] so you can cut out a lot of that, that’s what I'm saying. So that you don't need so much time for care planning either. ’ By using technology in the care process (e.g. in planning nursing interventions or completing documentation) more extensively and in a responsible and meaningful way, the participants believe that more time resources can be made available. They emphasize that it is important to have training in the use of technology in order for them to make efficient use of the technology. Another possibility to strengthen older persons’ self-care abilities is involving their relatives as they can provide support in the care process. Participants promote ‘ […] training of relatives in nursing activities’ (RLTC 2.2) and see community nurses as an opportunity to strengthen the relatives’ skills in nursing and see a possible impact on personnel shortages. Nurses also discuss that with less family members involved in care, there is also a shortage of relatives, which makes it difficult to integrate relatives into care and can put people in care without relatives at a disadvantage, which led them to the theme of the idea ranked second: to ‘ coordinate care for the older person between services ’ Coordinate Care for the Older Person Between Services The second highest ranked idea was that the care an older person receives needs to be better coordinated between different institutions and setting. Participants noted that ‘[...] there are already a lot of organisations and hospitals that are jumping on the bandwagon [coordinating intra- and extramural care]’ (HCCN 1.4). Even though they see lighthouse projects making initial efforts, they see opportunities to further strengthen the care of older people. They say: ‘Many people are no longer mobile and can’t go to their GP [general practitioner], but they [GPs] don't make home visits. They actually fall completely through the cracks if there is no one to make home visits.’ (HCCN 1.4). The participants say that community nurses would be a great resource to strengthen care at home and to coordinate different institutions and settings. For example, HCCN 1.5 says: ‘ It's not just the home visits that are needed, it's making contact while the patient is still in hospital. That I go there as a CN [community nurse].’ Community nurses accompanying the older person from the acute setting to the home setting can be a resource for persons in care to help minimise the feeling of being overwhelmed when coming home from hospital with new care needs. The participants think that community nurses should then explain everything to the patient again (e.g. diagnoses) and educate the older person receiving care and their family on care needs (e.g. leaving the hospital with a urinal catheter or wound they have to take care of at home) if needed according to their care needs. They stress that planning the care at home should already start (case and care management) upon admission to the acute care setting. Another way to facilitate this process is to have all institutions, professions, and settings use the same information system, so that, for example, nurses working in the community or in a person's home, and the person being cared for, have access to all the information they need. Nurses find it difficult to communicate and share information efficiently, they say: ‘ In principle, similar things are done [by different professions] and often what is actually needed at that moment isn’t being done. ’ (HCCN 1.3). That led participants to their third ranked theme of ideas, promoting and strengthening the interprofessional team. Promoting and Strengthening the Team The team, mostly consisting of physicians, nurses and nursing assistants should, according to participants, work on an equal footing, and should always focus on the best interests of persons in care. RLTC 1.1 says: ‘Because I believe that if the team functions harmoniously within itself, then it also responds better to the older person.’ To achieve this goal, nurses propose strengthening flat hierarchies with good communication skills and a positive work culture in the interprofessional team and in the nursing profession itself. The key is to utilize a person's skills and to promote a skill- and grade-mix in nursing. ‘ Actually, it's about making use of all competences of every professional group anyway, isn't it? [...] I mean above all this skill grade mix. Making full use of it all. ’ , says RLTC 2.2. Further to these top three ideas (see Table 4), nurses discussed their desire to strengthen the image and value of geriatric nursing by giving nurses more competencies and more opportunities for academic and continuous education, and by speaking publicly about the strengths and positives aspects of geriatric nursing (e.g. job rotations, or showing the public how diversified the field of geriatric nursing can be). Furthermore, nurses discussed the necessity of early preventive, and personalised interventions to promote a healthy life for as long as possible and therefore wish to strengthen health promotion at schools. When older persons move to a residential care facility, nurses suggest that the facility be more careful when accepting new residents. They also suggest that nurses are consulted to ensure that the residential care facility is the right place for each person's individual care needs as they have more expertise in assessing the needs of the older person. In the theme ‘ Promote focused training and professional development’ nurses suggest that more focused geriatric continuous education is offered to nurses with and without a diploma. Furthermore, they suggest that nurses attend courses at nurses’ undergraduate education facilities so that they can refresh and update their knowledge and students can learn from their experience. Lastly, nurses insist that persons in care receive equal opportunities independently of their wealth, network, and amount of family support. In the final discussion of the workshops, nurses reflected positively on their ideas and said that it is their goal to provide best possible care ‘and the only way to do that is to interlink the care services so that the person, so to speak, with the clinical presentation, can be treated individually, despite the diversity.’ (HCCN 1.3) Discussion This study asked two research questions: (1) What do nurses value about working in geriatric care?, and (2) What are nurses’ ideas on how to address challenges in geriatric care? Nurses appreciate the gratitude they receive from those they care for and from their colleagues. They also value that they are able to support and challenge the self-care abilities of the older person they care for and the older person themselves. The participants also attributed empathy, sensitivity, and compassion to a skilled geriatric nurse. They also valued the expertise and knowledge in health care a geriatric nurse holds. In regard to the second question, three ideas for strengthening geriatric nursing were highlighted by the participants: (1) ‘Promoting and strengthening older persons’ self-care abilities , (2) ‘Coordinate care for the older persons between institutions’ , and (3) ‘Promoting and strengthening the interprofessional team’ . In a previous study conducted in Sweden, nurses stated that what they valued about geriatric nursing was that it has a holistic approach to care, that nurses are able to build long-term relationships with people in care and their families, and that they are able to deliver individualised and person-centred care [19]. Person-centred care means that the values and preferences of the person in receipt of care guide the care process aiming for realistic life and health goals [41]. By providing holistic care that takes into account the physical, psychological, sociological, and spiritual needs of a person [10], nurses appreciate being able to develop and use more than technical skills, which makes long-term care more complex than acute care [19]. The results of this study led to similar findings as participants also highly appreciated working within the family and related persons of older persons. Even though they also valued individualised and person-centred care, as well as the complexity and diversity of geriatric nursing saliently, it was not ranked top of the list, making the gratitude they receive by colleagues and persons in care more important to them. Receiving gratitude is closely related to the extent to which nurses are satisfied with the care they provide [42]. Furthermore, [43] receiving gratefulness and being grateful (e.g. being grateful to your colleague) positively affects job satisfaction by supporting resilience in stressful situations [43, 44]. It may therefore have an impact on staying in the profession, as job satisfaction is linked to turn-over rates [45]. This might be linked to Fishbein and Ajzen’s [23] Theory of Reasoned Action. Amongst others, experienced gratefulness and receiving gratefulness might lead nurses to form positive opinions about geriatric nursing which might then lead to greater job satisfaction and lower intentions to leave the profession [46-48]. Furthermore, an Austrian study showed that nurses’ positive experiences in contact with older persons in care had a positive influence on their attitudes towards older people as well as their perspectives on geriatric nursing [49]. A skilled nurse was described as having a high degree of empathy, sensitivity, and compassion and as having expertise, and knowledge in health care. In the concept of ‘skilled companionship’, nursing care is described as bringing together skills (i.e. scientific, nursing knowledge) and companionship (i.e. seeing the person they care for as an individual and being empathetic to their needs). Also, older persons state that these are qualities they would like to see in a skilled nurse, although they rarely experience them. Due to the stressful work environment , lack of a caring, patient-centred culture in nursing practice and lack of teamwork, ‘skilled companionship’ is often not practiced and leads to nurses being dissatisfied with the care they provide [50]. The number one theme relating to ideas for strengthening geriatric nursing was ‘ Promoting and strengthening older persons’ self-care abilities.’ A systematic review by Compton et al. [18] of the factors influencing nurses' or nursing students' decisions to enter or remain in geriatric nursing shows that nurses' work is influenced by organisational culture, for example the availability of resources (i.e. staff or equipment). For nurses to work in geriatric nursing, the work environment and structures in the institutions must be supportive. This means that institutions need to be aware of difficulties in the workplace and provide support. On the other hand, high workloads and insufficient staff prevented nurses from working in geriatric nursing. This led to the feeling of not being able to provide sufficient care to improve the quality of life of those being cared for [24]. Participants proposed integrating greater use of technology into the nursing process, for example when planning nursing interventions or completing documentation. According to international literature, technologies used include, for example, information and communication systems that comprise computerised decision support systems, electronic health records and are used to collect, store, and manage data of the person and in communication in health care. By using these tools, quality of care and patient safety can be improved as health-related information is registered and evaluated more clearly, for example to document allergies and medications. Furthermore, the use of this technology can lead to reduced workload, reduced physical and mental pressure, and higher efficiency of nurses [51]. Participants also wished to ‘ Coordinate care for the older person between institutions’ , and describe the principles of an integrated care system. An integrated care system is a system in which all services needed by an older adult (e.g. home care, acute care, social care, etc.) work together in a coordinated way in order to provide person-centred and holistic care [52]. The World Health Organization is working towards reaching an integrated care system in primary health and long-term care by providing a guideline describing key elements of an integrated care system such as the use of information, monitoring and evaluation systems that are linked between services, having well-trained and sufficient healthcare workers, and supporting family care givers [52, 53]. Furthermore, nurses stated that the use of a skill- and grade-mix is needed in nursing practice. Although it is well known on the international literature that a skill- and grade-mix is beneficial for nursing practice and the care provided, participants do not see its full potential being used in daily practice [54, 55]. Strengths and Limitations The freelisting interview and nominal group technique methods used in this study proved to be an efficient method to use with a target group that lacks time resources. Participants reported that the methods were easy for them to use and that they appreciated the process and outcome of both methods. A heterogeneous group of participants enabled us to gain insights into different perspectives and focuses of geriatric nursing. The rigour of this study was strengthened through member checks, peer debriefing and peer reviews. This study does, however, have certain limitations. One limitation is that it is recommended to use between 20 to 30 study participants in freelisting interviews in order to confidently portrait ranks [56]. In this study, only 12 participants were included. Sampling proved to be difficult as many nurses did not want to participate due to a lack of time resources. Therefore, nurses with a strong interest in geriatric care may have participated primarily. As this may have introduced a response bias, caution should be used in interpreting these data. Implications In nursing practice, it should be carefully considered which person possesses which competencies and tasks should be distributed accordingly to get the best out of the skill- and grade-mix in nursing practice and the interprofessional team. Furthermore, fostering a supportive work environment by providing adequate equipment, staff, and time to foster a skill-companionship relationship between the geriatric nurse and the person in their care might lead to higher job satisfaction. It is recommended that policy makers, nursing managers, and researchers give more voice to long-term care nurses as they work closely with the ageing population and see the needs that exist in practice, and are thus able to contribute important ideas for mastering the challenges in this field. In future research, a co-research design with long-term care nurses could be used to plan and implement an intervention such as the use of technology in the nursing process or interventions to foster a holistic care approach, in accordance with the nurses’ three ideas. To be able to depict if nurses’ positive opinions on geriatric nursing influence job satisfaction and their willingness to stay in the profession in accordance with the Theory of Reasoned Action [23], quantitative studies could be conducted using psychometrically validated scales assessing perception of geriatric care (e.g. the Perspective on Caring for Older People scale [57], the McCloskey/Mueller Satisfaction Scale [58], or the Nurse Turnover Intention Scale [59]). Conclusion This study provides an insight into nurses’ positive opinions on geriatric nursing and what their ideas are for tackling challenges in geriatric nursing. Participants highlighted the importance of receiving gratitude from colleagues and care recipients, working within the family and with related persons of older persons, and providing individualised, person-centred care. Nurses identified three ideas for strengthening geriatric nursing: (1) promoting and strengthening selfcare-abilities of older people, (2) improving coordination of care across settings, and (3) improving interprofessional collaboration. Listening to long-term care nurses who have expert insights into the care needs of an ageing population voice their ideas can help in working towards provision of high-quality geriatric care. Use of a co-research design could be considered, for example, in planning target group and setting-specific measures in geriatric nursing in accordance with nurses’ ideas on interventions to provide holistic care for tackling challenges in geriatric nursing. In nursing practice, a supportive work environment that can help address workforce shortages and improve job satisfaction should be promoted. By working towards these measures, geriatric nursing can be strengthened to provide sustainable, high-quality support for an ageing population. Abbreviations SRQR Standards for Reporting Qualitative Research checklist WHO World Health Organization Declarations Ethics approval and consent to participate The ethics committee of the Medical University of Graz (EK Number 31–320 ex 18/19) gave their approval for this study. Participants gave written informed consent. Participants could withdraw from the study at any given time. Consent for publication Not applicable Availability of data and materials The dataset used in the current study is not available because the anonymity of the participants cannot be guaranteed. Competing interests The authors declare that they have no competing interests Funding No funding was received. Authors' contributions LML: conceptualisation, data curation, formal analysis, investigation, methodology, project administration, writing – original draft EP: data curation, formal analysis, investigation, writing (review and editing) CL: supervision, writing (review and editing) FG: conceptualisation, investigation, methodology, supervision, writing (review and editing) Acknowledgements The authors would like to thank the Doctoral School of the Medical University of Graz for their support, as well as all participants in this study. References Lampersberger LM, Schüttengruber G, Lohrmann C, Großschädl F. “The supreme discipline of Nursing”–A qualitative content analysis of nurses' opinions on caring for people eighty years of age and older. Heliyon . 2024;10(5) Che CC, Chong MC, Hairi NN. What influences student nurses’ intention to work with older people? A cross-sectional study. 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The impact of digital technologies in nursing care and their application: A narrative review. J Multidiscip Care . 2022;11(3):149-56. 10.34172/jmdc.2022.1127 World Health Organization. Integrated care for older people - Realigning primary health care to respond to population ageing Geneva, Switzerland2018. Available from: https://iris.who.int/bitstream/handle/10665/326295/WHO-HIS-SDS-2018.44-eng.pdf?sequence=1 [Accessed: 29.01.2024]. World Health Organization. Framework for countries to achieve an integrated continuum of long-term care 2021. Available from: https://www.who.int/publications/i/item/9789240038844 [Accessed: 03.02.2025]. Aiken LH, Sloane D, Griffiths P, Rafferty AM, Bruyneel L, McHugh M, et al. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Quality & Safety . 2017;26(7):559. 10.1136/bmjqs-2016-005567 Koopmans L, Damen N, Wagner C. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6342610","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":436176778,"identity":"1a2fa3af-63fc-4d10-b515-74878f1f8510","order_by":0,"name":"Lena Maria LAMPERSBERGER","email":"data:image/png;base64,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","orcid":"","institution":"Medical University of Graz","correspondingAuthor":true,"prefix":"","firstName":"Lena","middleName":"Maria","lastName":"LAMPERSBERGER","suffix":""},{"id":436176779,"identity":"826a9390-77f1-4ece-98ff-3c62f61aaf0a","order_by":1,"name":"Eva POCK","email":"","orcid":"","institution":"Medical University of Graz","correspondingAuthor":false,"prefix":"","firstName":"Eva","middleName":"","lastName":"POCK","suffix":""},{"id":436176780,"identity":"3523f2b3-86ab-4ce4-9e09-2c1ba1e86007","order_by":2,"name":"Christa LOHRMANN","email":"","orcid":"","institution":"Medical University of Graz","correspondingAuthor":false,"prefix":"","firstName":"Christa","middleName":"","lastName":"LOHRMANN","suffix":""},{"id":436176781,"identity":"13dd5a8f-84fc-479e-b61b-331cc69f05f8","order_by":3,"name":"Franziska GROSSSCHÄDL","email":"","orcid":"","institution":"Medical University of Graz","correspondingAuthor":false,"prefix":"","firstName":"Franziska","middleName":"","lastName":"GROSSSCHÄDL","suffix":""}],"badges":[],"createdAt":"2025-03-31 07:40:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6342610/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6342610/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-025-03793-4","type":"published","date":"2025-09-01T15:57:24+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79833700,"identity":"252546e9-321e-411d-86ea-2a14ff03b28d","added_by":"auto","created_at":"2025-04-03 11:00:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30033,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of the five phases of the workshop\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-6342610/v1/8288f718db4153b006ab811f.png"},{"id":90827944,"identity":"d0f921c6-4cc1-4c92-86ce-4db6a1621259","added_by":"auto","created_at":"2025-09-08 16:03:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":803141,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6342610/v1/2180ad0e-b503-44e9-b57c-5ce004daa2a6.pdf"},{"id":79833701,"identity":"d0e0f46d-53e7-4603-ad39-1893a5442757","added_by":"auto","created_at":"2025-04-03 11:00:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":249047,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6342610/v1/86a932a349a693d19eeb68ce.pdf"},{"id":79834418,"identity":"8d316d85-833c-4b5e-b7ee-bf068491d909","added_by":"auto","created_at":"2025-04-03 11:08:57","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":276477,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6342610/v1/2c4dd33c83dd9781fdea1dbf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Austrian Nurses’ Positive Opinions on Geriatric Care and Their Ideas for Tackling Challenges in Caring for the Ageing Population– A Modified Focus Group Study in Long-Term Care","fulltext":[{"header":"Background","content":"\u003cp\u003e\u0026lsquo;\u0026lsquo;\u003cem\u003eCaring for older people can be challenging, beautiful, and rewarding\u0026rsquo; [\u0026hellip;] (QN 103, 34 years, long-term care)\u003c/em\u003e\u0026rsquo; [1, p. 8] was written by a nurse about the care of older people in a study assessing nurses\u0026rsquo; experiences and opinions on caring for older people [1]. Although this quote reflects a positive opinion about geriatric nursing, an international body of research shows that the career choice of geriatric nursing is not a popular one among nursing students and nurses [2-4].The global nursing community is currently facing a shortage in personnel [5, 6], a situation compounded also by the demographic shift towards an ageing population [7]. However, it is predicted that in future there will be a greater demand for well-trained and specialised geriatric nurses, in order to ensure that the quality of nursing care for older people with a need for care due to higher rates of care dependency and care needs [6, 8, 9].\u003c/p\u003e\n\u003cp\u003eWhen a person\u0026rsquo;s need for care arises, holistic nursing interventions must be taken in an equipped care system to ensure that people in need of care receive appropriate and timely care to meet their physical, mental, social, and spiritual needs. Holistic nursing interventions focus on these physical, psychological, sociological, and spiritual needs of a person rather than on their disease or care need [10]. The need for holistic care of the ageing population is often met through long-term care [11]. The WHO (World Health Organization) defines long-term care as activities \u0026lsquo;\u003cem\u003eto ensure that people with or at risk of a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity\u0026rsquo;\u003c/em\u003e [11, p. 7].\u003cem\u003e\u0026nbsp;\u003c/em\u003eLong-term care aims to provide care for people who need assistance with activities of daily living to maintain functional ability [11]. It focuses on the health, personal care, and social needs of people in care [11]. In the field of long-term care, the demographic of service users is mostly composed of older people where frequently assistance is needed with activities of daily living [12, 13].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis care can be provided in a variety of settings, including the person\u0026apos;s home, the community, or residential long-term care facilities [11].\u0026nbsp;Depending on the level of care needed, older people prefer to stay in their own homes or in familiar surroundings if they have moderate care needs, but prefer residential care if they have greater care needs [14]. To ensure that long-term care is sufficient and sustainable, sufficient numbers of well-trained nurses are needed in this setting to provide appropriate, high-quality care in the right setting for each individual [7].\u003c/p\u003e\n\u003cp\u003eNursing professionals, including qualified nurses and nursing assistants make up the majority of the long-term care workforce besides informal caregivers [5, 6]. According to Eurofound [6], it is concerning that in Austria three out of four people working in acute or long-term care have considered leaving their position as it is estimated that in future 5-10 % more qualified nurses will be needed in long-term care.\u0026nbsp;Working conditions (physical workload, mental workload, and time pressure) have an impact on the willingness to continue working in long-term care [15].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLooking at the working conditions prevalent in European long-term care, there are several points of criticism voiced by nurses such as low pay, low quality of working time (e.g., part-time work, shift work, and working at short notice), high emotional demands [6], and a high risk of experiencing forms of violence (e.g., verbal or sexual harassment or physical violence) [6, 16]. In a study conducted among Austrian nurses, it was found that working conditions (e.g. lack of resources to provide quality care, consequences for physical, and mental health) were more often criticised than the geriatric nursing profession itself [1]. These factors increase the exposure of nurses to the risks of impaired physical, and mental health, occupational accidents, cardiovascular diseases, burn-out, depression, injuries, lower job satisfaction, and higher employee turnover rates [6, 16, 17]. Furthermore, due to these factors, nurses have the feeling of not being able to provide sufficient care to improve the quality of life of those being cared for as they lack the time to, for example [18]. In a Swedish study, nurses perceived geriatric nursing positively as holistic and respectful work where they could build long-term relationships with the persons they care for and their families and provide individualized and person-centred care [19]. These positive opinions of nurses on geriatric nursing influence their intentions to embark on a career in geriatric nursing or to stay in the profession [3, 20-22], which might be explained by the Theory of Reasoned Action [23].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFishbein and Ajzen\u0026rsquo;s [23] Theory of Reasoned Action shows that opinions are formed by experiences, interactions with a person, or by information from an outside source. By forming these opinions, one links attributes to an object (e.g. geriatric nursing) which are evaluated (positively, negatively, or neutrally) and lead to the formation of attitudes (e.g. towards geriatric nursing). The sum of opinions and attitudes towards something then influences one\u0026rsquo;s intention to perform a specific behaviour (e.g. not considering a career in geriatric nursing, leaving the profession) [23]. Since Covid 19, the pandemic has taken a toll on health care and on long-term care and the nursing shortage has intensified [24]. Nurses\u0026apos; opinions about long-term care may now be more critical and negative, as the work has become more demanding and nurses criticised the work environment repeatedly meaning that their interactions and experiences with geriatric nursing is more strained\u0026nbsp;[1, 18]. In the international literature, there is a lack of recent research on long-term care nurses\u0026apos; perceptions of long-term care and on what strengths they see in their work. Furthermore, the voice of nurses regarding what they need to provide care in a way that they, as experts, consider to be of high quality is rarely heard [1, 18]. In the light of a global ageing population and nursing staff shortages, this knowledge might be needed in order to plan target group and setting specific interventions supporting geriatric care in a way that is meaningful and needed by those who are affected [24]. Therefore, in this study we aim to investigate nurses\u0026rsquo; priorities with regard to two research questions:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eWhat do nurses value about working in geriatric care?\u003c/li\u003e\n \u003cli\u003eWhat are nurses\u0026rsquo; ideas on how to address challenges in geriatric care?\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is a descriptive qualitative study using a modified focus group method including freelisting interviews [25] and the nominal group technique [26]. These methods are especially suitable for target groups with a high workload and lack of time resources [25, 27]. We therefore deemed these methods suitable for focus groups including nurses who work in a stressful and understaffed environment [24]. In addition, freelisting interviews can reveal the priorities and attitudes of a culture [25], and the nominal group technique is particularly useful for focus groups where the goal is to generate ideas and find consensus on their priorities [26, 27]. The Standards for Reporting Qualitative Research (SRQR) checklist was used to guide the reporting of this study [28].\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eSetting and Participants\u003c/h2\u003e\n\u003cp\u003eIn this study, long-term care is defined as care provided by nurses in a long-term care facility, at home, or in the community, including nursing homes, home care, and community care. Nurses working in long-term care in southern Austria were invited to join the focus groups planned as a workshop and entitled \u0026lsquo;What do you wish for? Ideas for strengthening geriatric nursing\u0026rsquo;. Nurses with a diploma, specialised nurses (i.e. with a Bachelor degree or a diploma), or nurses without a diploma who actively worked in geriatric nursing were invited to participate. In Austria, nurses earn either a Bachelor degree or a diploma after completing a three-year training programme. After graduating, they can specialise in areas such as intensive or palliative care by completing a one-year university course. Nurses without a diploma can specialise by attending training lasting one or two years. Since all these nursing professions work in geriatric nursing [29], they were included in this study.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eSampling\u003c/h2\u003e\n\u003cp\u003eTwo sampling methods were used to recruit participants for this study: (1) convenience sampling and (2) snowball sampling (1). At the beginning of January 2025, an invitation to participate in the workshop and a flyer including information about the workshop were mailed to all residential and home care facilities, to nursing managers in these facilities, and to community nurses in a city in southern Austria and the surrounding area. A list of mail addresses was retrieved from government homepages [30-33]. The nurses were asked to forward the invitation and flyer to their network and to other nurses who might be interested in participating. Reminders were sent out two weeks later. Invitations were sent only to institutions in this particular city and its surrounding areas as the workshop was held at the local Medical University and to ensure short commutes for participants. The flyer was also shared on social media platforms (LinkedIn and Instagram) at the beginning of January 2025 and reposted twice in the following month. The local nursing association and local stakeholder also shared the invitation via their social media channels. Use of social media platforms was chosen to increase the possibility of reaching interested nurses who might not have received an invitation. (2) Nurses in the researchers\u0026rsquo; network were asked directly if they wanted to participate, were given a flyer and were asked to bring interested colleagues to the workshop. The aim was to recruit participants for two workshops with 6-10 participants each as according to the literature this is the ideal group size for conducting meaningful discussions [34].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn total, 12 nurses participated in the two workshops. They had a median age of 34.5 years and a median geriatric working experience of 9 years. The demographic and professional characteristics of these participants can be found in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1 Demographic and professional characteristics of participants (N = 12)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 183px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eSex\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eProfession\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eNurse with a diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eNurse without a diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eSetting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eResidential long-term care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eHome and community care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch2\u003eFocus Groups\u003c/h2\u003e\n\u003cp\u003eWe conducted two focus groups in February 2025. The focus group was designed as a workshop for nurses to work on ideas regarding challenges in geriatric nursing. Two researchers facilitated the workshop, with one (LML) leading the workshop and the other (EP) taking notes, making audio recordings of discussion phases, and preparing data from the freelisting interviews and the nominal group technique for presentation to the participants at the end of the workshop.\u003c/p\u003e\n\u003cp\u003eThe workshop consisted of five phases and lasted for three hours: (1) welcoming the participants and collecting demographic data, (2) an icebreaker task to get the participants in the mood for the topic and to create a basis for discussion, (3) two freelisting interview questions to assess positive opinions on geriatric nursing and what qualities they attribute to a skilled geriatric nurse, (4) collecting and prioritising ideas for tackling challenges in geriatric nursing using the nominal group technique, and (5) discussing the results. Figure 1 shows an overview of the five phases of the workshop, which are also described in detail below.\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAt the beginning of the workshop participants were welcomed by the researchers and the researchers and the participants introduced themselves. Each participant was handed a package of materials that included the written informed consent, a questionnaire on demographic data, sheets for freelisting, and sheets for the nominal group technique. Demographic data included sex and age of participants, followed by questions about their work. They were asked about their profession, the setting in which they work, and the number of years they have worked in geriatric nursing.\u003c/li\u003e\n \u003cli\u003eNext, the workshop leader explained the steps included in the workshop and gave a brief overview on what the workshop is about. As an icebreaker, participants thought about how they would complete this sentence: \u0026lsquo;\u003cem\u003eGeriatric nursing for me is ...\u003c/em\u003e\u0026rsquo;. They were then asked to share their understanding of geriatric nursing with the group, if they were willing.\u003c/li\u003e\n \u003cli\u003eTwo questions were worked on with the freelisting interview technique. The first was \u0026lsquo;\u003cem\u003eWhat do you value about your work in geriatric nursing?\u003c/em\u003e\u0026rsquo; and the second was \u0026lsquo;\u003cem\u003eWhen you think of a colleague whom you consider to be a skilled geriatric nurse, what makes them special?\u003c/em\u003e\u0026rsquo;. Participants were asked to list anything that came to mind on a prepared sheet. They were given 5 minutes per question. If participants were still listing items after five minutes, they were given more time. Freelist interviews identify items in a cultural domain or emic category and show what is most important or salient to the participants as they tend to list familiar items first [25].\u003c/li\u003e\n \u003cli\u003eIn the nominal group technique phase, the participants focused on one question: \u0026lsquo;\u003cem\u003eIf you could change five things about your current working day, what would they be?\u003c/em\u003e\u0026rsquo;. The nominal group technique has four stages [26]: (1) The first stage, \u0026lsquo;idea generation,\u0026rsquo; consists of each participant writing down ideas individually, one idea per card. In our workshop, participants had to write down five ideas each and were given 10 minutes. (2) The second stage is called \u0026apos;round robin\u0026apos;, where participants say their ideas one by one and stick them on a flipchart. In this stage, the ideas were not discussed or clarified. 15 minutes were allotted for this stage. (3) The third stage was a group discussion of the ideas generated. In this stage, ideas could be clarified, discussed, grouped or further divided until a consensus was reached in the group. In addition, an audio recording was made of the discussion. The workshop leader recorded the agreed ideas and their explanations on a whiteboard. (4) Finally, in the fourth stage, participants voted on their top three ideas and ranked them using a prepared sheet. This stage lasted 5 minutes.\u003c/li\u003e\n \u003cli\u003eAt the end of the workshop, the results of the freelisting interviews and the nominal group technique were presented to and discussed with the participants. An audio recording was also made of this discussion.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch2\u003eData Processing and Analysis\u003c/h2\u003e\n\u003cp\u003eLike the focus groups, the analysis also consisted of several stages. First, demographic data were analysed using descriptive statistics in Microsoft Excel (Microsoft Office LTSC Profssional Plus 2021) [35]. Notes of the icebreaker task were entered into the software MAXQDA 2020 [36]. Second, freelists were entered by one researcher into Microsoft Excel (Microsoft Office LTSC Profssional Plus 2021) [35]. The participants and two groups were pooled and synonymous items were grouped into one item. This process was checked for accuracy by a second researcher. This resulted in one list per question. A salience analysis was performed on these two lists. This involved calculating the salience of each item on each participant\u0026apos;s list. The ranked items were numbered inversely and divided by the total number of items. The composite salience value was then calculated by dividing the sum of salience per item by the number of participants. There are no clear boundaries for what value is considered salient, thus we determined the salience of items according to breaks in the data visualised by bar graphs (see Additional File 1 and Additional File 2) [25]. Third, the nominal group technique was analysed integrating both groups according to the method proposed by Van Breda [37]. The ideas generated were entered into Microsoft Excel [35] spreadsheets and the top five ideas were identified by average scores. Each first-ranked idea received 15 points, second-ranked ideas received 10 points, and third-ranked ideas received 5 points. A content analysis of the generated ideas was then performed in MAXQDA 2020 [36], and overarching themes of ideas were defined. The content analysis was performed by one author and peer reviewed by a second author. Finally, the combined ranks of both groups were calculated by a \u0026lsquo;top 5 score\u0026rsquo; that includes only rated ideas, a \u0026lsquo;number score\u0026rsquo; that includes the frequency of themes, and an \u0026lsquo;average score\u0026rsquo; that standardizes the score of ideas independent of group size. [37]. The audio-recorded discussions were transcribed using NoScribe (version 0.6) [38] and checked for accuracy by one of the researchers. Quotes included in the results have been translated into English by one author and DeepL Translator (Version 24.11.4.14424) [39] and checked by a bilingual English native speaker.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEthical Considerations\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the Medical University of Graz (EK Number 31\u0026ndash;320 ex 18/19). Participants signed a written informed consent and were informed that they could withdraw from the study at any time. Digital data is stored on the university\u0026apos;s secure network and written data is stored securely at the university. Only the researchers have access to the data. \u003c/p\u003e\n\u003ch2\u003eRigour\u003c/h2\u003e\n\u003cp\u003eTo enhance trustworthiness and credibility, the two researchers (LML and EP) that were involved in holding the workshops met beforehand to discuss the workshop guide in detail and to reflect on their possible influence on the process and on participants. To ensure authenticity, both researchers are nurses with a diploma, experienced in the geriatric setting. Following the first workshop, the understandability of methods and questions were evaluated with the participants and discussed by the two researchers. No changes were made. After each workshop, peer debriefing was carried out as the researchers reflected again on possible influences they had on the discussions and on group dynamics. To ensure reliability and validity of the data, member checks were carried out by presenting results of the workshop to the participants at the end of the workshop. The participants had the opportunity to discuss the results, confirm their validity, and to add additional remarks. The data analysis was performed by one author and peer reviewed by a second author. If necessary, discrepancies were discussed until a consensus was reached. Every step of analysis was discussed by the two authors involved in the analysis process [40].\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe workshops began with nurses reflecting on what geriatric nursing means to them. Overall, it was discussed that a central part of geriatric nursing for them was the complexity and diversity of the field involving caring for people with co-morbidities. In addition, the provision of individualised and holistic care that promotes resources and goes beyond mere care to help shape the daily lives of older people was seen as a core skill of geriatric nursing. It is the nurse who is primarily responsible for the care and well-being of older persons.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter this initial icebreaker exercise, the workshop moved on to the freelisting interviews. In response to the question \u003cem\u003e\u0026apos;What do you value about your work in geriatric nursing\u0026apos;\u003c/em\u003e, the most salient item was that nurses experience a lot of gratitude or appreciation for their work, either from their colleagues or from the people they care for. Nurses also have a positive opinion regarding the opportunity to support and challenge the self-care abilities of the older person they care for and the older person themselves. This was followed by the opportunity to work with the older person they care for, their families, and their relatives. All salient items generated by the nurses in relation to valuing geriatric nursing can be found in Table 2 and all generated items can be found in Additional File 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 Freelist of salient items of nurses\u0026rsquo; positive opinions on geriatric nursing (N = 12)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 415px;\"\u003e\n \u003cp\u003e\u0026lsquo;\u003cem\u003eWhat do you value about your work in geriatric nursing?\u003c/em\u003e\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003eComposite Salience\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eLots of gratitude/appreciation (persons they care for/colleagues)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eSupporting and challenging care needs and older person themself\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eWorking with\u0026nbsp;the family and relatives of older persons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eTeamwork/support/help within the team\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eWide-ranging/complex field of activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eProviding support and involvement in the everyday life of the older person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eAutonomy/taking responsibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003ePersonalised care planning according to needs/assessment of needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eCommunication/listening/talking/laughing/crying together\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eEnabling years of healthy life/quality of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eWorking in a multi-professional team, utilising networks and interprofessional approaches\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eWorking with people\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 160px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 661px;\"\u003e\n \u003cp\u003eNote: Higher composite salience scores indicate higher salience, composite salience is calculated by numbering the ranks per list per participant inversely and divided by the total number of items per list.\u0026nbsp;The composite salience value is then calculated by dividing the sum of salience per item by the number of participants on a combined list per question [25].\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAfter the second freelisting activity, the nurses collected items in response to the second question: \u003cem\u003e\u0026apos;When you think of a colleague whom you consider to be a skilled geriatric nurse, what makes them special?\u003c/em\u003e\u0026rsquo; The most salient point was that a skilled nurse has a high degree of empathy, sensitivity, and compassion. A skilled nurse also requires expertise and broad knowledge in health care, and takes time for the people in care, even when under stress. All salient items that nurses attribute to a skilled geriatric nurse can be found in Table 3, and all generated items can be found in Additional File 2.\u003c/p\u003e\n\u003cp\u003eTable 3 Freelist of salient items of what nurses consider to be a skilled geriatric nurse (N = 12)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 415px;\"\u003e\n \u003cp\u003e\u0026lsquo;\u003cem\u003eWhen you think of a colleague whom you consider to be a skilled geriatric nurse, what makes them special?\u003c/em\u003e\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eComposite Salience\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eHas a high degree of empathy/sensitivity/compassion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eHas expertise and knowledge in health care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eTakes their time (despite stress)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eIs very organised/structured/precise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eHas several years of professional experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eHas patience/a calm disposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eListens closely/has an open ear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eIs constantly learning, regularly participates in ongoing training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eShares knowledge/guides other employees/helps colleagues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eRespects individual wishes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eIs caring/has a gentle manner with older persons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eWorks with foresight, keeps sight of what\u0026rsquo;s important/able to assess situations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eIs motivated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eHas a sense of humour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eIs reliable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eAble to observe and perceive well\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003ePrioritises taking into account the environment of older persons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eCan express themself well/ has good communication skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0,13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 661px;\"\u003e\n \u003cp\u003eNote: Higher composite salience scores indicate higher salience, composite salience is calculated by numbering the ranks per list per participant inversely and divided by the total number of items per list.\u0026nbsp;The composite salience value is then calculated by dividing the sum of salience per item by the number of participants on a combined list per question [25].\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e[Add Table 3 here]\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter the nurses had discussed positive opinions on geriatric nursing and the attributes they assign to a capable geriatric nurse, the participants used the nominal group technique to develop their own ideas for strengthening geriatric nursing. This was guided by the question \u0026lsquo;\u003cem\u003eIf you could change five things about your current working day, what would they be?\u003c/em\u003e\u0026rsquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter the individual ideas were discussed in the groups and the researchers analysed the themes of the ideas collected and agreed upon, eight themes of ideas emerged (see Table 4). The three ideas that where most important to the participants and therefore ranked higher were (1) \u0026lsquo;Promoting and strengthening older persons\u0026rsquo; self-care abilities, (2) \u0026lsquo;Coordinate care for the older persons between services, and (3) \u0026lsquo;Promoting and strengthening the team\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003eTable 4 Ranking of generated ideas for strengthening geriatric nursing using the analysing method by Van Breda [37]\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThemes of ideas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTop 5 votes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAverage score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFinal rank score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePromoting and strengthening older persons\u0026rsquo; self-care abilities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e33.75\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e23\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoordinate care for the older persons between Services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e30\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e18.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePromoting and strengthening the team\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e15.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStrengthening the image and value of geriatric nursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFacilitating holistic prevention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eResidential long-term care as suitable place for individual old age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePromote focused training and professional development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePromoting equal opportunities for persons in care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp\u003eNote: Higher final rank scores indicate higher ranking of ideas, the top three ranked themes of ideas are presented in bold. Scores are calculated according to Van Breda [37]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003ePromoting and Strengthening Older Persons\u0026rsquo; Self-care abilities\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eStrengthening older persons\u0026rsquo; self-care abilities can on the one hand be reached on the part of the older person and on the other on the part of nurses, facilities and structures. To be able to provide care that promotes and strengthens the self-care abilities of older persons, participants discussed that holistic care is needed that is tailored to the older person based on their biography. They suggest that early on, when a need for care first arises, persons in care write down their needs and preferences. A nurse describes that \u003cem\u003e\u0026lsquo;[\u0026hellip;]\u0026nbsp;\u003c/em\u003e\u003cem\u003efor each activity of daily life, the person should write down how they would like it to be. For example, would they prefer a shower or a bath, warmer water or do they like it a little cooler\u003c/em\u003e\u003cem\u003e.\u0026rsquo;\u003c/em\u003e (HCCN 2.1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, on this topic nurses discussed that nursing services in particular are not sufficiently publicly funded, which leads to unequal opportunities for persons in care. They say: \u003cem\u003e\u0026lsquo;At the moment, it depends on whether I can afford it or not. It\u0026apos;s about equal opportunities.\u0026rsquo;\u003c/em\u003e (HCCN 1.3). They propose that home care, family caregivers, community nursing and social interventions should be better funded from public funds. They further discussed that to relieve the burden on family caregivers, it should be possible to receive funding for support provided by nursing professionals for a few hours a day. HCCN 1.3 states the problem: \u003cem\u003e\u0026lsquo;It is often the case that some people need support throughout the day [...] That they cannot provide home care for the entire day [...] That is not actually subsidised at all. You have to pay for it yourself.\u0026rsquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, participants discussed that in order to provide holistic care, they need more time with the person they care for, in addition to basic nursing interventions, for individual care, social interventions and preventive interventions. They suggest that more time resources can be made available by reducing bureaucracy and minimizing care planning to essential interventions. NH 2.2 for example proposes that: \u0026lsquo;\u003cem\u003eI find that many things, especially in care planning, are no longer all that up-to-date such as the housekeeping components, making the bed, for example, [...] so you can cut out a lot of that, that\u0026rsquo;s what I\u0026apos;m saying. So that you don\u0026apos;t need so much time for care planning either.\u003c/em\u003e\u0026rsquo; By using technology in the care process (e.g. in planning nursing interventions or completing documentation) more extensively and in a responsible and meaningful way, the participants believe that more time resources can be made available. They emphasize that it is important to have training in the use of technology in order for them to make efficient use of the technology.\u003c/p\u003e\n\u003cp\u003eAnother possibility to strengthen older persons\u0026rsquo; self-care abilities is involving their relatives as they can provide support in the care process. Participants promote \u003cem\u003e\u0026lsquo;\u003c/em\u003e\u003cem\u003e[\u0026hellip;] training of relatives in nursing activities\u0026rsquo;\u003c/em\u003e (RLTC 2.2) and see community nurses as an opportunity to strengthen the relatives\u0026rsquo; skills in nursing and see a possible impact on personnel shortages. Nurses also discuss that with less family members involved in care, there is also a shortage of relatives, which makes it difficult to integrate relatives into care and can put people in care without relatives at a disadvantage, which led them to the theme of the idea ranked second: to \u0026lsquo;\u003cem\u003ecoordinate care for the older person between services\u003c/em\u003e\u0026rsquo;\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCoordinate Care for the Older Person Between Services\u003c/h2\u003e\n\u003cp\u003eThe second highest ranked idea was that the care an older person receives needs to be better coordinated between different institutions and setting. Participants noted that \u003cem\u003e\u0026lsquo;[...] there are already a lot of organisations and hospitals that are jumping on the bandwagon [coordinating intra- and extramural care]\u0026rsquo;\u003c/em\u003e (HCCN 1.4). Even though they see lighthouse projects making initial efforts, they see opportunities to further strengthen the care of older people. They say: \u003cem\u003e\u0026lsquo;Many people are no longer mobile and can\u0026rsquo;t go to their GP [general practitioner], but they [GPs] don\u0026apos;t make home visits. They actually fall completely through the cracks if there is no one to make home visits.\u0026rsquo;\u003c/em\u003e (HCCN 1.4). The participants say that community nurses would be a great resource to strengthen care at home and to coordinate different institutions and settings. For example, HCCN 1.5 says: \u0026lsquo;\u003cem\u003eIt\u0026apos;s not just the home visits that are needed, it\u0026apos;s making contact while the patient is still in hospital. That I go there as a CN\u003c/em\u003e\u003cem\u003e\u0026nbsp;[community nurse].\u0026rsquo;\u003c/em\u003e Community nurses accompanying the older person from the acute setting to the home setting can be a resource for persons in care to help minimise the feeling of being overwhelmed when coming home from hospital with new care needs. The participants think that community nurses should then explain everything to the patient again (e.g. diagnoses) and educate the older person receiving care and their family on care needs (e.g. leaving the hospital with a urinal catheter or wound they have to take care of at home) if needed according to their care needs. They stress that planning the care at home should already start (case and care management) upon admission to the acute care setting.\u003c/p\u003e\n\u003cp\u003eAnother way to facilitate this process is to have all institutions, professions, and settings use the same information system, so that, for example, nurses working in the community or in a person\u0026apos;s home, and the person being cared for, have access to all the information they need. Nurses find it difficult to communicate and share information efficiently, they say: \u003cem\u003e\u0026lsquo;\u003c/em\u003e\u003cem\u003eIn principle, similar things are done [by different professions] and often what is actually needed at that moment isn\u0026rsquo;t being done.\u003c/em\u003e\u003cem\u003e\u0026rsquo;\u003c/em\u003e (HCCN 1.3). That led participants to their third ranked theme of ideas, promoting and strengthening the interprofessional team.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePromoting and Strengthening the Team\u003c/h2\u003e\n\u003cp\u003eThe team, mostly consisting of physicians, nurses and nursing assistants should, according to participants, work on an equal footing, and should always focus on the best interests of persons in care. RLTC 1.1 says: \u003cem\u003e\u0026lsquo;Because I believe that if the team functions harmoniously within itself, then it also responds better to the older person.\u0026rsquo;\u003c/em\u003e To achieve this goal, nurses propose strengthening flat hierarchies with good communication skills and a positive work culture in the interprofessional team and in the nursing profession itself. The key is to utilize a person\u0026apos;s skills and to promote a skill- and grade-mix in nursing. \u0026lsquo;\u003cem\u003eActually, it\u0026apos;s about making use of all competences of every professional group anyway, isn\u0026apos;t it? [...] I mean above all this skill grade mix. Making full use of it all.\u003c/em\u003e\u003cem\u003e\u0026rsquo;\u003c/em\u003e, says RLTC 2.2.\u003c/p\u003e\n\u003cp\u003eFurther to these top three ideas (see Table 4), nurses discussed their desire to strengthen the image and value of geriatric nursing by giving nurses more competencies and more opportunities for academic and continuous education, and by speaking publicly about the strengths and positives aspects of geriatric nursing (e.g. job rotations, or showing the public how diversified the field of geriatric nursing can be). Furthermore, nurses discussed the necessity of early preventive, and personalised interventions to promote a healthy life for as long as possible and therefore wish to strengthen health promotion at schools. When older persons move to a residential care facility, nurses suggest that the facility be more careful when accepting new residents. They also suggest that nurses are consulted to ensure that the residential care facility is the right place for each person\u0026apos;s individual care needs as they have more expertise in assessing the needs of the older person. In the theme \u0026lsquo;\u003cem\u003ePromote focused training and professional development\u0026rsquo;\u003c/em\u003e nurses suggest that more focused geriatric continuous education is offered to nurses with and without a diploma. Furthermore, they suggest that nurses attend courses at nurses\u0026rsquo; undergraduate education facilities so that they can refresh and update their knowledge and students can learn from their experience. Lastly, nurses insist that persons in care receive equal opportunities independently of their wealth, network, and amount of family support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the final discussion of the workshops, nurses reflected positively on their ideas and said that it is their goal to provide best possible care \u003cem\u003e\u0026lsquo;and the only way to do that is to interlink the care services so that the person, so to speak, with the clinical presentation, can be treated individually, despite the diversity.\u0026rsquo;\u0026nbsp;\u003c/em\u003e(HCCN 1.3)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study asked two research questions: (1)\u0026nbsp;What do nurses value about working in geriatric care?, and (2) What are nurses\u0026rsquo; ideas on how to address challenges in geriatric care? Nurses appreciate the gratitude they receive from those they care for and from their colleagues. They also value that they are able to support and challenge\u0026nbsp;the self-care abilities of the older person they care for and the older person themselves. The participants also attributed empathy, sensitivity, and compassion to a skilled geriatric nurse. They also valued the expertise and knowledge in health care a geriatric nurse holds. In regard to the second question, three ideas for strengthening geriatric nursing were highlighted by the participants: (1) \u003cem\u003e\u0026lsquo;Promoting and strengthening older persons\u0026rsquo; self-care abilities\u003c/em\u003e, (2) \u003cem\u003e\u0026lsquo;Coordinate care for the older persons between institutions\u0026rsquo;\u003c/em\u003e, and (3) \u003cem\u003e\u0026lsquo;Promoting and strengthening the interprofessional team\u0026rsquo;\u003c/em\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn a previous study conducted in Sweden, nurses stated that what they valued about geriatric nursing was that it has a\u0026nbsp;holistic approach to care, that nurses are able to build long-term relationships with people in care and their families, and that they are able to deliver individualised and person-centred care [19]. Person-centred care means that the values and preferences of the person in receipt of care guide the care process aiming for realistic life and health goals [41]. By providing holistic care that takes into account the\u0026nbsp;physical, psychological, sociological, and spiritual needs of a person [10], nurses appreciate being able to develop and use more than technical skills, which makes long-term care more complex than acute care [19]. The results of this study led to similar findings as participants also highly appreciated working within the\u0026nbsp;family and related persons of older persons. Even though they also valued individualised and person-centred care, as well as the complexity and diversity of geriatric nursing saliently, it was not ranked top of the list, making the gratitude they receive by colleagues and persons in care more important to them. Receiving gratitude is closely related to the extent to which nurses are satisfied with the care they provide [42]. Furthermore, [43] receiving gratefulness and being grateful (e.g. being grateful to your colleague) positively affects job satisfaction by supporting resilience in stressful situations [43, 44]. It may therefore have an impact on staying in the profession, as job satisfaction is linked to turn-over rates [45].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis might be linked to Fishbein and Ajzen\u0026rsquo;s [23] Theory of Reasoned Action. Amongst others, experienced gratefulness and receiving gratefulness might lead nurses to form positive opinions about geriatric nursing which might then lead to greater job satisfaction and lower intentions to leave the profession [46-48]. Furthermore, an Austrian study showed that nurses\u0026rsquo; positive experiences in contact with older persons in care had a positive influence on their attitudes towards older people as well as their perspectives on geriatric nursing\u0026nbsp;[49].\u003c/p\u003e\n\u003cp\u003eA skilled nurse was described as having\u0026nbsp;a high degree of empathy, sensitivity, and compassion and as having expertise, and knowledge in health care. In the concept of \u0026lsquo;skilled companionship\u0026rsquo;, nursing care is described as bringing together skills (i.e. scientific, nursing knowledge) and companionship (i.e. seeing the person they care for as an individual and being empathetic to their needs). Also, older persons state that these are qualities they would like to see in a skilled nurse, although they rarely experience them. Due to the stressful work environment , lack of a caring, patient-centred culture in nursing practice and lack of teamwork, \u0026lsquo;skilled companionship\u0026rsquo; is often not practiced and leads to nurses being dissatisfied with the care they provide [50].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe number one theme relating to ideas for strengthening geriatric nursing was \u0026lsquo;\u003cem\u003ePromoting and strengthening older persons\u0026rsquo; self-care abilities.\u0026rsquo;\u003c/em\u003e A systematic review by Compton et al. [18] of the factors influencing nurses\u0026apos; or nursing students\u0026apos; decisions to enter or remain in geriatric nursing shows that nurses\u0026apos; work is influenced by organisational culture, for example the availability of resources (i.e. staff or equipment). For nurses to work in geriatric nursing, the work environment and structures in the institutions must be supportive. This means that institutions need to be aware of difficulties in the workplace and provide support. On the other hand, high workloads and insufficient staff prevented nurses from working in geriatric nursing. This led to the feeling of not being able to provide sufficient care to improve the quality of life of those being cared for [24]. Participants proposed integrating greater use of technology into the nursing process, for example when planning nursing interventions or completing documentation. According to international literature, technologies used include, for example, information and communication systems that comprise computerised decision support systems, electronic health records and are used to collect, store, and manage data of the person and in communication in health care. By using these tools, quality of care and patient safety can be improved as health-related information is registered and evaluated more clearly, for example to document allergies and medications. Furthermore, the use of this technology can lead to reduced workload, reduced physical and mental pressure, and higher efficiency of nurses [51].\u003c/p\u003e\n\u003cp\u003eParticipants also wished to \u0026lsquo;\u003cem\u003eCoordinate care for the older person between institutions\u0026rsquo;\u003c/em\u003e, and describe the principles of an integrated care system. An integrated care system is a system in which all services needed by an older adult (e.g. home care, acute care, social care, etc.) work together in a coordinated way in order to provide person-centred and holistic care\u0026nbsp;[52]. The World Health Organization is working towards reaching an integrated care system in primary health and long-term care by providing a guideline describing key elements of an integrated care system such as the use of information, monitoring and evaluation systems that are linked between services, having well-trained and sufficient healthcare workers, and supporting family care givers [52, 53]. Furthermore, nurses stated that the use of a skill- and grade-mix is needed in nursing practice. Although it is well known on the international literature that a skill- and grade-mix is beneficial for nursing practice and the care provided, participants do not see its full potential being used in daily practice [54, 55].\u003c/p\u003e\n\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\n\u003cp\u003eThe freelisting interview and nominal group technique methods used in this study proved to be an efficient method to use with a target group that lacks time resources. Participants reported that the methods were easy for them to use and that they appreciated the process and outcome of both methods. A heterogeneous group of participants enabled us to gain insights into different perspectives and focuses of geriatric nursing. The rigour of this study was strengthened through member checks, peer debriefing and peer reviews. This study does, however, have certain limitations. One limitation is that it is recommended to use between 20 to 30 study participants in freelisting interviews in order to confidently portrait ranks [56]. In this study, only 12 participants were included. Sampling proved to be difficult as many nurses did not want to participate due to a lack of time resources. Therefore, nurses with a strong interest in geriatric care may have participated primarily. As this may have introduced a response bias, caution should be used in interpreting these data.\u003c/p\u003e\n\u003ch2\u003eImplications\u003c/h2\u003e\n\u003cp\u003eIn nursing practice, it should be carefully considered which person possesses which competencies and tasks should be distributed accordingly to get the best out of the skill- and grade-mix in nursing practice and the interprofessional team. Furthermore, fostering a supportive work environment by providing adequate equipment, staff, and time to foster a skill-companionship relationship between the geriatric nurse and the person in their care might lead to higher job satisfaction. It is recommended that policy makers, nursing managers, and researchers give more voice to long-term care nurses as they work closely with the ageing population and see the needs that exist in practice, and are thus able to contribute important ideas for mastering the challenges in this field. In future research, a co-research design with long-term care nurses could be used to plan and implement an intervention such as the use of technology in the nursing process or interventions to foster a holistic care approach, in accordance with the nurses\u0026rsquo; three ideas. To be able to depict if nurses\u0026rsquo; positive opinions on geriatric nursing influence job satisfaction and their willingness to stay in the profession in accordance with the Theory of Reasoned Action [23], quantitative studies could be conducted using psychometrically validated scales assessing perception of geriatric care (e.g. the Perspective on Caring for Older People scale [57], the McCloskey/Mueller Satisfaction Scale [58], or the Nurse Turnover Intention Scale [59]).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides an insight into nurses\u0026rsquo; positive opinions on geriatric nursing and what their ideas are for tackling challenges in geriatric nursing. Participants highlighted the importance of receiving gratitude from colleagues and care recipients, working within the family and with related persons of older persons, and providing individualised, person-centred care. Nurses identified three ideas for strengthening geriatric nursing: (1) promoting and strengthening selfcare-abilities of older people, (2) improving coordination of care across settings, and (3) improving interprofessional collaboration. Listening to long-term care nurses who have expert insights into the care needs of an ageing population voice their ideas can help in working towards provision of high-quality geriatric care. Use of a co-research design could be considered, for example, in planning target group and setting-specific measures in geriatric nursing in accordance with nurses\u0026rsquo; ideas on interventions to provide holistic care for tackling challenges in geriatric nursing. In nursing practice, a supportive work environment that can help address workforce shortages and improve job satisfaction should be promoted. By working towards these measures, geriatric nursing can be strengthened to provide sustainable, high-quality support for an ageing population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSRQR \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;Standards for Reporting Qualitative Research checklist\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThe ethics committee of the Medical University of Graz (EK Number 31\u0026ndash;320 ex 18/19) gave their approval for this study. Participants gave written informed consent. Participants could withdraw from the study at any given time.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used in the current study is not available because the anonymity of the participants cannot be guaranteed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLML: conceptualisation, data curation, formal analysis, investigation, methodology, project administration, writing \u0026ndash; original draft\u003c/p\u003e\n\u003cp\u003eEP: data curation, formal analysis, investigation, writing (review and editing)\u003c/p\u003e\n\u003cp\u003eCL: supervision, writing (review and editing)\u003c/p\u003e\n\u003cp\u003eFG: conceptualisation, investigation, methodology, supervision, writing (review and editing)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the Doctoral School of the Medical University of Graz for their support, as well as all participants in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLampersberger LM, Sch\u0026uuml;ttengruber G, Lohrmann C, Gro\u0026szlig;sch\u0026auml;dl F. \u0026ldquo;The supreme discipline of Nursing\u0026rdquo;\u0026ndash;A qualitative content analysis of nurses\u0026apos; opinions on caring for people eighty years of age and older. \u003cem\u003eHeliyon\u003c/em\u003e. 2024;10(5)\u003c/li\u003e\n \u003cli\u003eChe CC, Chong MC, Hairi NN. 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Causes of employee turnover: A test of the Mobley, Griffeth, Hand, and Meglino model. \u003cem\u003eJournal of applied psychology\u003c/em\u003e. 1982;67(1):53.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Long-term care, geriatric nursing, ageing population, nominal group technique, freelisting interviews","lastPublishedDoi":"10.21203/rs.3.rs-6342610/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6342610/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground:\u003c/p\u003e\n\u003cp\u003eAs the demand for long-term care increases due to a global ageing population, ensuring continuous and high-quality geriatric nursing is crucial. However, geriatric nursing faces challenges such as workforce shortages, high workload, and high emotional demand, which can impact quality of care, job satisfaction, and intentions to leave the profession. Little is known about nurses’ opinions on geriatric nursing and their ideas for addressing challenges in caring for the ageing population. This study aims to explore what nurses in Austria value about working in geriatric nursing and their ideas on addressing challenges in geriatric nursing.\u003c/p\u003e\n\u003cp\u003eMethods:\u003c/p\u003e\n\u003cp\u003eA descriptive qualitative study was conducted using a modified focus group approach that included freelisting interviews and the nominal group technique. Two focus groups in the form of workshops were held in 2025 with 12 nurses working in long-term care in Austria. The freelisting data were analysed using salience analysis, while the ranked ideas generated in the nominal group technique were analysed using Van Breda’s method of ranking. Descriptive statistics were used to summarise participant demographics.\u003c/p\u003e\n\u003cp\u003eResults:\u003c/p\u003e\n\u003cp\u003eNurses valued the appreciation they received from older persons they care for and colleagues, the opportunity to work within the family and related persons of older persons, and their ability to provide individualized and person-centred care. A skilled geriatric nurse was described as having empathy, sensitivity, and broad expertise in health care. The three highest-ranked ideas for strengthening geriatric nursing were (1) Promoting and strengthening older persons’ self-care abilities (e.g. providing holistic, individualised care), (2) Coordinate care for the older persons between services, and (3) Promoting and strengthening the team.\u003c/p\u003e\n\u003cp\u003eConclusions:\u003c/p\u003e\n\u003cp\u003eThese findings suggest that strengthening geriatric nursing requires structural improvements, enhanced collaboration across healthcare sectors, and recognition of nurses’ competencies. Implementing a supportive work environment, optimising skill- and grade-mix approaches, and listening to nurse’s expert insights may contribute to sustainable and high-quality long-term care for the aging population. Future research should consider a co-research design to plan target group and setting specific interventions in geriatric nursing based on nurses' ideas.\u003c/p\u003e","manuscriptTitle":"Austrian Nurses’ Positive Opinions on Geriatric Care and Their Ideas for Tackling Challenges in Caring for the Ageing Population– A Modified Focus Group Study in Long-Term Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-03 11:00:52","doi":"10.21203/rs.3.rs-6342610/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-17T07:10:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-16T13:47:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-16T13:45:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-03-31T07:36:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f808eb85-6e1b-4bc7-8888-8ae3070c7cf0","owner":[],"postedDate":"April 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T15:59:59+00:00","versionOfRecord":{"articleIdentity":"rs-6342610","link":"https://doi.org/10.1186/s12912-025-03793-4","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2025-09-01 15:57:24","publishedOnDateReadable":"September 1st, 2025"},"versionCreatedAt":"2025-04-03 11:00:52","video":"","vorDoi":"10.1186/s12912-025-03793-4","vorDoiUrl":"https://doi.org/10.1186/s12912-025-03793-4","workflowStages":[]},"version":"v1","identity":"rs-6342610","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6342610","identity":"rs-6342610","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}