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Advancing home health nursing competencies in Canada to reflect a dynamic care environment and complex population health needs: a modified eDelphi study

BMC Nursing volume 24, Article number: 378 (2025) Cite this article

Abstract

Background

Home health nursing competencies outline the knowledge, skills and attributes home health nurses need for safe and ethical practice. Since the Canadian Home Health Nursing Competencies were first developed in 2010, several important contextual changes have occurred. To ensure competencies reflect current practice contexts, this study aimed to update Canada’s home health nursing competencies.

Methods

A four-phase modified eDelphi study was conducted using online surveys, consensus meetings and feedback forms. An environmental scan was conducted to identify home health competencies emerging since 2010, to create a comprehensive set of preexisting competencies to serve as the starting point for a 3-round modified eDelphi process. The eDelphi was conducted with a panel of home health nurses (n = 43) to identify core competencies relevant to current home health nursing practice environments. Broader consultations with home health nurses (n = 41) and interdisciplinary home care team members (n = 12) were held to validate eDelphi findings. An advisory working group (n = 24) of home health nursing leaders provided guidance on study decision-making and final recommendations.

Results

Three hundred fifty-nine preexisting competencies were consolidated into 96 unique home health nursing competencies. In Round 1 of the eDelphi, home health nurses reached consensus (agreement ≥ 75%) that 94 competencies were relevant to current practice environments and suggested five new competencies. Subsequent eDelphi rounds resulted in 93 competencies being brought forward as both relevant and essential for current home health nursing practice. Further consultations refined recommendations, resulting in a final set of 79 competencies. Qualitative feedback provided insights into the relevance and importance of competencies, opportunities for comprehension improvements, and implementation considerations.

Conclusions

The home health nursing competency set generated through this study incorporates core concepts in home health nursing practice, such as evidence-informed practice and interdisciplinary collaboration, along with several new concepts, such as trauma-informed care, data-driven decision-making, and provision of culturally safe care. This updated competency set can be used to inform prelicensure education and professional development opportunities to enhance home health workforce capacity. Future work exploring strategies to support competency uptake in education and home and community care organizations is needed.

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Background

In Canada, it is estimated that the number of older adults needing home and community care will more than double from 345 000 people in 2019 to 770 000 people by 2050 [1]. This increasing demand is driven by factors such as the growing aging population, older adults’ preference to age at home, shifts toward shorter hospital stays and new care models that aim to support acute care needs in the community [1,2,3,4,5,6,7,8,9,10]. Unpaid caregivers often support the majority of older adults’ care in community settings; however, as the availability of family caregivers continues to decline [1, 11], formal home and community care services are becoming increasingly important to ensure that older adults have options to age at home [1, 12]. Together, these factors have resulted in significant changes in the care environment and growing expectations for home and community care nurses to possess expanded skillsets.

The increased demand for home and community care is occurring at a time when the sector, and the healthcare system more broadly, is experiencing workforce stabilization challenges in Canada and internationally [13,14,15,16,17,18]. A 2021 survey conducted by the Ontario Community Support Association revealed that 26% of registered nurse positions in home and community care were vacant, a significant increase from previous years [13], with national data also showing a decline in the number of nurses working in community care [19, 20]. Inadequate staffing in home and community care can result in missed care and increased workload for existing staff [21], negatively influencing job satisfaction, quality of care, mental health and burnout [22,23,24]. These challenges can perpetuate high staff turnover rates [17, 25, 26], resulting in increased recruitment and training costs for new staff to fill vacancies [24]. The reduced availability of home care for home care recipients can also lead to admission to facility-based long-term care [12]. Strategies to recruit, retain and strengthen the home and community care workforce are therefore important to meet the care needs of Canadians aging at home [27].

Home health nurses, including licensed or registered practical nurses, registered nurses, and nurse practitioners, play a significant role in the delivery of home and community care [9]. Nurses have over-arching guiding documents such as codes of ethics [28, 29] and entry-to-practice competencies [30, 31] that serve as the foundation for all nursing practice. While these documents serve a critical purpose, home health nursing practice involves unique challenges and work environments that distinguish it from other types of nursing [32,33,34]. Home health nurses often practice autonomously with asynchronous delivery of interdisciplinary care in unstructured and unpredictable work environments [32, 33, 35]. Home health nurses take on a wide range of responsibilities, including clinical care, client and family education, case management and social support [33]. The assessment of care needs and delivery of care must be considered in the context of clients’ goals, strengths, needs and environment (e.g., home environment, availability of social support) [36]. Owing to these differences, experienced nurses transitioning from other practice environments to home care report experiencing a steep learning curve [34]. The evidence also suggests that prelicensure educational opportunities in home and community nursing may not be adequate, related to factors such as a lack of instructors with home health nursing experience, a lack of community placement opportunities, and the use of simulation rather than clinical placements [37]. Given the distinctive features of the home health nursing role and environment and the increasing demand for care in the community, it is important that training opportunities align with the skills and knowledge required by the nursing workforce to meet population care needs in the home and community sectors [27, 34].

Recognizing that home health nursing is a specialty area of practice, the Community Health Nurses of Canada (CHNC), a voluntary professional home health nursing association, developed the Canadian Community Health Nursing Standards of Practice (the Standards), which define the scope of community health nursing practice [38], and the Home Health Nursing (HHN) Competencies, which outline the key knowledge, skills, and personal attributes required for safe and ethical home health nursing practice that facilitate achieving the Standards [39, 40]. The Standards were first developed in 2003, with revisions taking place in 2008, 2011 and again in 2019 to address the changing complexities in service delivery, reflect important national healthcare reforms (e.g., the Truth and Reconciliation Commission of Canada: Calls to Action [41]) and align with legislative requirements resulting from changes such as the legalization of medical assistance in dying in 2016 [42]. The Standards define eight overarching areas of practice for home health nurses: (1) health promotion; (2) prevention and health protection; (3) health maintenance, restoration and palliation; (4) professional relationships; (5) capacity building; (6) health equity; (7) evidence informed practice; and (8) professional responsibility and accountability [38]. The HHN Competencies were developed in 2010 [39] based on a literature review [43] and an expert consensus process [44]. A set of 78 competencies, grouped into three high-level domains, outlined the required unique knowledge base, focusing on (1) key elements of home health nursing practice (e.g., care planning and coordination, communication, relationships); (2) foundational home health nursing skills (e.g., health promotion, illness prevention); and (3) quality and professional responsibility [39]. Since their release, these competencies have been used to guide both preservice education and professional development opportunities for home health nurses to ensure that training opportunities align with the skills and knowledge needed for this role [37, 45]. However, as the competencies were developed prior to the most recent revision of the Standards, there is not direct alignment between the competencies and the Standards. Furthermore, regular revision of competencies is essential to ensure that they remain relevant in dynamic practice contexts. Since their development and release, several important contextual changes have motivated calls to review and revise the 2010 HHN Competencies, including (1) the increase in digital health and telemedicine use, which steadily increased prior to 2020 but rapidly accelerated during the COVID-19 pandemic [46, 47]; (2) the hospital capacity crisis, growth in transitional care and hospital-at-home programs, and the increased complexity of care needs being encountered by home and community care nurses [9, 48, 49]; and (3) the growing ethnocultural diversity in Canada and increased recognition of the influence of cultural factors on health and well-being [50, 51].

Study aims and objectives

The aim of this study was to develop a national set of core competencies for the delivery of safe and ethical home health nursing that reflect current Canadian home care practice contexts. To achieve this aim, the study had four overarching objectives: (1) to assess the continued applicability of the HHN Competencies developed by CHNC in 2010 [39] to the current home care context in Canada; (2) to identify additional competencies required to accurately reflect the current home health nursing practice environment in Canada; (3) to reach consensus among home health nurses and practice leaders on the core set of national competencies; and (4) to validate the importance and comprehensiveness of the set of core competencies with interdisciplinary home care team members.

Methods

Study design

A four-phase, mixed-method modified eDelphi study [52] was conducted between December 2023 and October 2024 (Fig. 1) and is reported using the ACcurate COnsensus Reporting Document (ACCORD) (Additional File 1) [53]. A Delphi study is a structured research method which synthesizes the opinions of a set of individuals with expertise in a defined content area to systematically build consensus on a given topic or research question [52]. Globally, the Delphi method has been widely used in the identification and development of nursing competencies [54,55,56,57,58]. A modified eDelphi approach was chosen to allow us to build from established home health nursing competencies (e.g. [39]), and to facilitate the engagement of home health nurses across Canada via an online and asynchronous consensus-building process. The design and delivery of this eDelphi study were guided by the six practical steps outlined by Belton et al. [52]. The study protocol was not registered but is available upon request.

Fig. 1
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Study phases and main activities

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Participants

Four participant groups were engaged as part of this study: (1) an advisory working group of home health nursing leaders; (2) a panel of home health nurses; (3) a panel of interdisciplinary home care team members; and (4) attendees of a preconference workshop focused on home health nursing competencies held as part of a community health nursing conference.

Advisory working group

A pan-Canadian Advisory Working Group (AWG) was established by CHNC at the beginning of the project. Members of the AWG were active CHNC members and other individuals with varied expertise working in Canadian home health nursing. Membership represented a range of roles (e.g., point-of-care, clinical management, operational leadership, research, and education) and geographies. Given the breadth and depth of expertise represented on the AWG, a non-probabilistic, pragmatic sampling approach was employed to invite all AWG members to participate in the study in an advisory capacity, supporting eDelphi panel recruitment and guiding decision-making through a series of virtual consensus meetings and asynchronous (email) feedback opportunities [59]. AWG members provided feedback on the organization and wording of the initial set of competencies shared in the eDelphi process as well as the final competency set. AWG members who regularly participated in study activities were eligible for a $50.00 CAD e-gift card at the end of data collection.

Nursing panel

A convenience, stratified quota sampling approach [60] was employed to recruit a heterogeneous panel of home health nurses representing point-of-care, management/leadership, and research/education perspectives to participate in the eDelphi process. In Canada, home health nurses include registered nurses (typically university-prepared with a bachelor’s degree), registered or licensed practical nurses (typically college-prepared with a diploma degree), and nurse practitioners (registered nurses with a master’s degree or post-graduate certificate) [61]. A target panel size of 50 was selected to support the inclusion of diverse perspectives and account for known attrition in eDelphi panels [62]. Given the goal of developing a set of national competencies that reflects the current home health nursing practice context across Canada, recruitment efforts aimed at representing all ten provinces and three territories with no more than 20% of panel participants from any one province or territory. Furthermore, a priori recruitment targets (60% point-of care, 20% management or leadership, and 20% research or education) were collaboratively established by the research team and AWG to support the inclusion of a variety of perspectives but keep focused on creating applied, point-of-care competencies. To participate in the nursing panel, individuals were required to be a registered nurse, a registered or licensed practical nurse or a nurse practitioner licensed to practice in any Canadian jurisdiction and have experience working in home and community care settings in Canada. AWG participants were not eligible to participate in the nursing panel.

Nursing panel participants were recruited via the research team and AWG member networks using email invitation scripts and social media posts. Eligibility screening was conducted via an online survey supplemented by a follow-up phone call with a member of the research team to confirm eligibility and prevent fraudulent or bot-generated responses [63]. Potential participants were asked to provide their professional designation, self-identified practice perspective (i.e., point-of-care, management/leadership, research/education), and province to facilitate the stratified sampling approach. Nursing panel participants who completed the eDelphi process were offered a $50.00 CAD e-gift card as a thanks for their time and expertise. Nursing panel participants were not aware of other panel members’ identities at any point in the eDelphi process to minimize bias from groupthink or dominant voices that may occur in synchronous group meetings [52].

Interdisciplinary

Interdisciplinary home care team panel

A panel of interdisciplinary home care providers was recruited to provide feedback on the draft competency set established through the eDelphi process using a convenience, stratified sampling approach [60]. Recruitment materials were shared via email and social media posts leveraging the networks of the research team and AWG. A target panel size of 10, representing a geographically and professionally diverse sample, was collaboratively established by the research team and AWG. Personal support workers, occupational therapists, physiotherapists, social workers, dieticians, speech language therapists, respiratory therapists, primary care providers, geriatricians, or pharmacists licensed to practice in any Canadian jurisdiction, with experience working collaboratively with home health nurses in home and community care settings in Canada were eligible to participate. After completing the survey, interdisciplinary panel participants were offered a $10.00 CAD e-gift card to thank them for their time and expertise. Panel participants were not aware of the identities of other panel members.

Workshop attendees

Following completion of the eDelphi process, additional feedback on the draft competency set was sought from home health nurses (including registered nurses and registered practical nurses) registered to attend a full-day, in-person, preconference workshop focused on home health nursing competencies in Canada. A convenience sampling approach [60] was used to invite all registered workshop attendees who had not already participated in the nursing panel or AWG to provide written feedback regarding the relevance and importance of the competencies. No remuneration was provided for workshop participation.

Data collection

Data collection was performed in four phases: (1) identifying preexisting competencies; (2) generating the competency set; (3) achieving consensus; and (4) validating competencies (Fig. 1). All surveys were administered online via Qualtrics (Provo, UT), with survey links sent individually to participants via personalized email. Pilot testing was conducted for each survey by research team members and/or AWG members to assess the ease of comprehension and usability. Participants were given up to 10 days to complete each survey with the ability to save progress, and two email reminders were sent if needed.

AWG consensus meetings

Throughout the data collection process, feedback was obtained from the AWG through a series of four online consensus meetings using the Microsoft Teams platform and through asynchronous written feedback via email and online surveys. Feedback from the AWG informed: wording of competencies identified in the environmental scan prior to use in the eDelphi process (Consensus Meeting 1; feedback form), inclusion of new competencies and wording changes on the basis of qualitative feedback from the Round 1 eDelphi survey (Consensus Meeting 2; online survey), final mapping of new and unmapped competencies to the Canadian Community Health Nursing Standards of Practice (Consensus Meeting 3; online survey and feedback form), and final decisions regarding the inclusion or exclusion of competencies that did not reach clear consensus based on nursing panel results and consultation feedback (Consensus Meeting 4; online voting).

Phase 1: Identifying preexisting competencies

Phase 1 addressed Research Objective 1, identifying home health nursing competencies published since 2010 in the grey literature by nursing organizations and associations worldwide or in the academic literature. An environmental scan was conducted from December 2023 to January 2024. Searches were conducted via Google Scholar. To be included, documents had to present competency domains, statements and/or standards focused on the delivery of home health care. All identified competencies were collated and brought forward for consideration. When equivalent competencies were identified in multiple source documents, consolidated statements were drafted by the research team. When available, the competency statement from the 2010 HHN Competencies [39] was used as the starting point. Statements were then revised to include additional content identified in equivalent competencies from other source documents as appropriate. These consolidated competency statements were then mapped to the most relevant Canadian Community Health Nursing Standard of Practice [38]. For competencies that did not clearly align with an existing Standard, two additional categories were developed to support the mapping process: (1) Cross-Cutting Competencies for competencies that aligned with more than one standard; and (2) Unmapped Competencies.

Phase 2: Generating the competency set

Phase 2 focused on building a comprehensive set of competencies to serve as the basis for the consensus process. Leveraging the consolidated competency set from the environmental scan, Phase 2 addressed Research Objectives 1 and 2 by assessing the continued relevance of the identified competencies and generating additional competencies required to accurately reflect the current home health nursing practice environment. In the first eDelphi survey, background characteristics of nursing panel members were collected, including their professional designation, area of practice (e.g., point-of-care, management, education), length of time working in home and community care, year of birth, province/territory, population density of the region in which they live (e.g., metropolitan, urban or rural), gender, and whether they identified as a member of a visible minority or as Indigenous. Panel members were then asked to rate their level of agreement with the statement, This competency isrelevantto present-day home health nursing practice in Canada, using a 7-point Likert-type scale (1– Strongly disagree, 2–Disagree, 3–Somewhat disagree, 4–Neither agree nor disagree, 5–Somewhat agree, 6–Agree, 7–Strongly agree). If desired, participants could provide comments to justify their response, improving the quality and relevance of feedback [52]. Competencies identified as relevant (i.e., rated as 5–Somewhat agree, 6–Agree or 7–Strongly agree) by 75% or more of the nursing panel were retained for subsequent survey rounds [57]. To generate additional competencies which panel participants felt would be necessary to safely and ethically practice home health nursing in Canada, an open-ended question was included at the end of the survey. Additional competencies suggested by the nursing panel, which were endorsed by a majority of AWG members completing an online feedback survey, were included in subsequent survey rounds.

Phase 3: Achieving consensus

Phase 3 consisted of two more eDelphi survey rounds focused on determining which of the relevant and new competencies identified in Phase 2 were viewed as essential to current home health nursing practice to address Research Objective 3. Prior to Round 2, nursing panel members were provided with a personalized summary report of Round 1 findings, including their own response and overall panel response (e.g., mode, interquartile range) for each competency. In the Round 2 survey, nursing panel members were asked to rate how important each competency is to the safe and ethical home health nursing practice in Canada using a 7-point Likert-type scale (1–Not at all important, 2–Unimportant, 3–Somewhat unimportant, 4–Neither important nor unimportant, 5–Somewhat important, 6–Important, 7–Essential). If desired, participants could provide comments to justify their response, improving the quality and relevance of feedback [52]. Competencies identified as 6–Important or 7–Essential by 75% or more of the panel and with a mode of 7–Essential were considered to have achieved consensus.

Competencies that did not reach the threshold for consensus were included in the Round 3 survey. In Round 3, nursing panel members were again asked to rate the importance of the competencies. To support consensus-building, participants were provided with a personalized summary report of their Round 2 survey individual item responses, along with the overall panel response distribution. Competencies identified as important or essential by 75% or more of the panel and with a mode of 7 - Essential were considered having achieved consensus. Again, participants could provide comments to justify their response if desired [52].

To map new competencies generated during the eDelphi process and competencies in the Unmapped Competencies category from the environmental scan to the most appropriate Standard of Practice, we used a two-step process. First, as part of the Round 3 survey, the home health nursing panel was asked to assign any new or unmapped competencies to the most appropriate Standard of Practice. Then, where agreement was not reached (i.e., 75% or more), the most highly endorsed Standards of Practice for each competency were presented to the AWG for additional input and feedback to support final decision-making.

Phase 4: Validating competencies

The final phase of the study focused on validating results from the nursing panel and obtaining feedback on the comprehensiveness of the draft set of core competencies more broadly, including the perspectives of interdisciplinary home care team members (Research Objective 4). To do this, two additional consultation sessions were held between April and May 2024. The first consultation was held with interdisciplinary home care team members via an online survey, and the second consultation involved preconference workshop attendees using a paper-based worksheet. Interdisciplinary home care team members’ background characteristics were obtained via the online survey, including their professional designation, area of practice (e.g., point-of-care, management, education), length of time working in home and community care, year of birth, province/territory, population density of the region in which they live (e.g., metropolitan, urban or rural), gender, and whether they identified as a member of a visible minority or as Indigenous. Preconference workshop attendee background characteristics, including professional designation, area of practice (e.g., point-of-care, management, education), length of time working in home and community care, province/territory, population density of the region in which they live (e.g., metropolitan, urban or rural), and gender, were obtained via a paper-based worksheet.

During interdisciplinary home care team and preconference workshop consultations, participants were asked if each competency was (1) relevant (yes/no), and (2) essential (yes/no) to safe and ethical home health nursing practice in Canada. In both consultations, participants were provided an opportunity to provide open-ended comments as desired [52]. Workshop attendees completed a paper-based worksheet, which was then transcribed by the research team. For the consultations, consensus cutoffs were inverted (e.g., considered not relevant or not essential if 25% or more of respondents within each consultation selected “no” for the relevant question). This change was made to account for missing data in calculations because workshop feedback was provided on paper, with responses to questions being optional.

The results of the nursing panel, interdisciplinary home care team consultation and preconference workshop were collated and brought to the final AWG consultation (Consensus Meeting 4). The goal of this final consultation was to make a final decision on the set of core competencies to be recommended, with parsimony being identified as a key value in decision-making. A summary of consultation feedback from across sources was presented, with time allocated for discussion, and a live vote was conducted via an online poll. In the poll, AWG members were asked if the competency should be (1) included (or recommended for inclusion with modifications (e.g., wording)) or (2) excluded from final recommendations. Competencies with 75% of meeting attendees voting to include/modify were retained in the final competency set.

Data analysis

Descriptive statistics (means and standard deviations for continuous variables and frequencies for categorical variables) were used to describe study participant characteristics. Descriptive statistics (percentages, modes and interquartile ranges) were used to analyze the Nursing Panel and Interdisciplinary Home Care Team Panel surveys, preconference workshop worksheet data, and AWG feedback (e.g., feedback from online surveys and live voting). Quantitative data were analyzed using SPSS (SPSS, Chicago, IL, USA).

Qualitative data from open-ended questions were analyzed using an inductive content analysis approach [64, 65]. Qualitative data were coded by one research team member using short phrases to capture meaning, and codes with similar meanings were then grouped into categories [64, 65]. Categories were reviewed and revised by three other members of the research team.

Results

Participant demographics

Across the four phases of this study, 120 home care experts from 11 provinces and territories in Canada were engaged and provided feedback on the competency set. Demographic details of all study participants are available in Table 1. Twenty-four individuals participated in Advisory Working Group consensus meetings representing eight Canadian provinces and territories. AWG members primarily held management and leadership (n = 11) or education and academic roles (n = 10) across government agencies (n = 6), service provider organizations (n = 11), and academic institutions (n = 5). Forty-four home health nurses were recruited and eligible to take part in the eDelphi process, with 98% (n = 43) completing the Round 1 survey. Panel attrition over the three eDelphi rounds was 23%, aligned with expected panel attrition rates in eDelphi studies [62]. Analyses comparing the demographic characteristics of participants who started and completed the eDelphi process are available in Additional File 2. No significant differences in demographic characteristics were observed between the nursing panel members who started and those who completed all the eDelphi survey rounds (p > 0.05). Twelve individuals representing nine professional groups were recruited for the interdisciplinary home care team panel. Panel members represented three provinces, primarily holding point-of-care roles (n = 9). Finally, forty-one nurses representing seven provinces provided feedback on competencies through the preconference workshop. Most workshop participants reported holding management/leadership roles (n = 24) in home care. Overall, a geographically diverse sample of home care nurses with roles spanning practice, management, education and research provided insight and feedback on the final competency set.

Table 1 Study participant characteristics
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Phase 1 Results

Identifying preexisting competencies

The environmental scan identified 5 source documents containing home health nursing competencies and standards [33, 38, 39, 55, 66]. A total of 359 competencies were identified across all the source documents. After competency statements with the same meaning were consolidated, 96 unique competency statements were generated, with 76 mapped to one of the Canadian Community Health Nursing Standards of Practice, 6 mapped to the Cross-Cutting Competencies category, and 14 mapped to the Unmapped Competencies category.

Results of the environmental scan were presented to the AWG at Consensus Meeting 1, including an overview of the concepts in the identified competency statements and how they were mapped to the Standards. Discussions were held at the Standard of Practice / category level, centering around considerations of language, appropriateness of the mapping of concepts and identification of missing content. Detailed written feedback on the environmental scan results and mapping at the individual competency level was received from eight (33%) AWG members following Consensus Meeting 1.

Phase 2 Results

Generating the competency set

Forty-three (98% response rate) nursing panel participants completed Round 1 of the eDelphi process. Consensus was reached among panel members that 94 (98%) preexisting competencies were relevant for safe and ethical home health nursing practice in Canada (see Additional File 3 for competency-specific data). Two competencies that did not reach consensus in Round 1 were removed from further consideration. Seven additional competency statements were suggested by nursing panel members and were presented to the AWG for discussion at Consensus Meeting 2 to inform decision-making regarding their inclusion in subsequent eDelphi survey rounds. Five of the seven competency statements suggested by the nursing panel were approved for inclusion in subsequent eDelphi survey rounds by the AWG via an online survey (n = 9). The two competency statements not approved for inclusion were noted to be too narrow in focus (competency focused explicitly on Veteran populations) or as already captured (competency focused on reflexive practice). The five competency statements approved for inclusion focused on (1) understanding and applying the principles of trauma-informed care; (2) supporting community engagement through community resource directories; (3) promoting self-management; (4) applying occupational health and safety principles; and (5) advocating for appropriate staffing levels and staff mix.

Phase 3 Results

Achieving consensus

In Round 2, the panel members were asked to consider whether the 99 competency statements deemed relevant in Round 1 were also considered important for safe and ethical nursing practice in Canada. Thirty-seven (response rate = 87%) nursing panel members completed the Round 2 survey. Fifty-one (52%) competencies reached consensus, including five Cross Cutting, four Health Promotion, two Prevention and Health Protection, seven Health Maintenance, Restoration and Palliation, six Professional Relationships, three Capacity Building, five Health Equity, three Evidence Informed Practice, seven Professional Responsibility and Accountability, seven Unmapped Competencies, and two new competencies generated in Round 1 (see Additional File 3 for competency specific details).

In the Round 3 survey, panel members were presented with the remaining 48 (48%) competency statements which had not yet reached consensus, along with a report of their individual Round 2 responses and information about the panel’s response distribution. The Round 3 survey was completed by 34 (77%) nursing panel members. In this round, a further 11 competencies reached consensus and were included in the final competency set including three Health Promotion, two Professional Relationships, two Health Equity, three Professional Responsibility and Accountability and one Unmapped Competency. Six (6%) competencies that were not rated as important by at least 75% of the panel in Round 2 continued to be considered unimportant in Round 3 and were removed from further consideration. The remaining 31 (31%) competencies continued to be rated as important by at least 75% of the panel but only with a mode of “important”, therefore not reaching the definition of consensus. These competencies were the focus of further consultations and feedback to enable decision-making regarding their inclusion in the updated set of home health nursing competencies. After three rounds of the eDelphi process, 62 (63%) competencies met consensus as being relevant and important to home health nursing practice, 31 (31%) competencies met consensus as being relevant but required additional feedback to determine their importance, and 8 (8%) competencies were removed from further consideration.

As part of the Round 3 survey, panel members were asked to assign each of the 5 new competencies and the 14 unmapped competencies to their most appropriate Standard. There was low agreement (21–56%) among the panel regarding which Standard was most appropriate for each new or unmapped competency, with none of the 19 competencies meeting mapping consensus criteria (e.g., 75%). Following Round 3, agreement was established that one of these 19 competencies was not essential to practice. It was removed from further consideration and the mapping process. To support decision-making for mapping the remaining 18 competencies, in Consensus Meeting 3, up to four of the most highly endorsed Standards for each competency were presented to the AWG, and feedback was collected via an online survey. Thirteen AWG members (54%) provided feedback, resulting in the mapping of nine competencies (50%) to Professional Responsibility and Accountability, three competencies (17%) to Professional Relationships, two (11%) competencies to Health Promotion, two (11%) competencies to Health Maintenance, Restoration, Palliation, one (6%) competency to Prevention and Health Protection, and one (6%) competency to Cross Cutting Competencies (Table 2).

Table 2 Home health nursing panel (n = 34) and AWG (n = 13) competency mappinga
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Phase 4 Results

Validating competencies

All 93 competencies that met the consensus requirements in the eDelphi process were presented for validation and feedback to the Interdisciplinary Home Care Team panel and preconference workshop attendees. The interdisciplinary panel confirmed all 93 (100%) competencies as relevant and 92 (99%) competencies as essential. Preconference workshop attendees confirmed 89 (96%) competencies as relevant and 76 (82%) as essential. Finally, written feedback was obtained from AWG members (n = 10) following discussion at Consensus Meeting 3 regarding the importance of the 31 relevant competencies that failed to meet consensus as essential (see Additional File 3 for details).

Final recommendations

Following the eDelphi process and consultations, consensus was reached that 71 competencies were both relevant and essential to current practice and that eight competencies were not relevant and/or essential. However, 22 competencies remained, which did not reach consensus. As a final step, data regarding the relevance and importance of each competency not reaching consensus were compiled from across all study phases (e.g., the nursing panel, interdisciplinary panel, preconference workshop and Consensus Meeting 3) and qualitative comments provided by participants were summarized and presented to the AWG at Consensus Meeting 4. Following discussion and an online vote, agreement was reached that eight of the 22 competencies should be included. Therefore, a total of 79 competencies were included in the final recommended set of home health nursing competencies (Fig. 2 and Additional File 4).

Fig. 2
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Detailed flow diagram of the competency development process

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Qualitative feedback

Qualitative feedback was received throughout the four study phases. The qualitative comments reflect three categories: comprehension improvements, implementation considerations, and relevance and importance. Exemplifying participant comments for each category are available in Additional File 5.

Comprehension improvements

Comprehension improvements included recommendations for streamlining competencies to reduce redundancies and wordiness through rephrasing and combining similar competencies or improving organization by adjusting competency mapping. Language changes were also suggested to ensure that consistent terminology was used across competency statements (e.g., interdisciplinary versus interprofessional, terminology referring to the client’s social support network) and that the implied level of responsibility was appropriate for the home health nursing role (e.g., creating versus using resources, leading versus collaborating).

Don’t think the role [of the home health nurse] is to create [resource] directories, but be aware of resources. – Workshop attendee (PC28)

Additional suggested language changes focused on ensuring that competencies were action oriented and used nonjudgmental terminology (e.g., rephrasing terms such as “healthy” or “risky”). To support competency comprehension and address potential knowledge gaps, several terms, including critical social theory, social prescribing, strengths-based approach, and trauma-informed care, were identified as needing to be defined.

Implementation considerations

The current context was perceived as a potential barrier to fully implementing the competencies given that nursing shortages and increased complexity of home care clients’ needs have reduced home health nurses’ ability to integrate competencies into their practice.

The focus in home care as of late has been one of a sort of drive through service… go in provide care and leave. The foundation of home care needs to shift back to its roots. These competencies will never fully be adopted if systemic change does not occur. - Nursing panel participant (ND20)

A perceived lack of opportunities to engage with work related to some of the competencies, such as engaging with policy and advocacy work, was also observed, as this participant shared:

Being involved in big system advocacy and transformation is not really a focus or even possible as a result of the nursing shortage and those of us who are left working with clients who are more complex than ever. We don’t have time or resources to do this in the 21st century. - Nursing panel participant (ND100)

Additionally, existing resources and the current care and payment models were not viewed as supporting competency implementation (e.g., some resources are not inclusive of equity-deserving populations). With respect to competencies focused on the use of technology and electronic health records, some participants commented that they still used paper charting in their daily practice and that some settings, such as First Nations communities, lacked infrastructure (e.g., reliable internet access) to support use of electronic systems.

Participants also identified a need for education and training to support competency implementation. Professional development needs related to working with Indigenous populations and incorporating the Truth and Reconciliation Commission of Canada Calls to Action related to health and healthcare within their practice were identified. Other areas where additional training would be appreciated included providing culturally safe and trauma-informed care, engaging in evidence-informed decision making, and building skills related to teaching, delegation and leadership. Additionally, some requested greater clarity on how to implement some competencies, for example, understanding historical causes of illness or evaluating the impact of capacity-building efforts.

Relevance and importance

Participant comments emphasized the importance and value of the updated competency set, noting their comprehensive nature and how key concepts important to their practice were captured, including competencies focused on health equity, trauma-informed care, and interprofessional collaboration.

Super valid! Trauma is a consideration not often thought of. - Workshop attendee (PC08)

However, participants also identified some competencies they felt were less important for home health nurses or were more generic and expected of all practicing nurses; therefore, they should not be designated as a competency unique to home health nursing. Some competencies were viewed as being out of the scope of point-of-care nurses (e.g., competencies related to research and policy) or more appropriate for higher-level roles such as managers or practice leads (e.g., identification and appraisal of research evidence to guide practice). Finally, some comments about competencies focused on Indigenous populations expressed anti-Indigenous racism, calling for equal treatment for all rather than equitable treatment for Indigenous persons based on the principle of justice.

Additional concepts and skills were identified that should be added (e.g., skills related to motivational interviewing, recognizing clients’ spiritual needs) or further emphasized (e.g., evaluation and efficiency of care, recognition of the impact of negative past experiences with the healthcare system) in future iterations of the competencies to further enhance their relevance and importance.

Discussion

An updated set of home health nursing competencies reflecting the current care context was generated through consensus and consultation methods with home health nurses and interdisciplinary home care team members from across Canada. Engagement of home health nurses working in different roles and settings supported the inclusion of diverse perspectives in the competency generation process, which helped ensure that the competencies reflected current practice realities across different contexts in Canada. Feedback from home health nurses identified the need for resources and education to support comprehension and implementation of the updated competencies in these diverse practice settings [67].

Key changes in updated home health nursing competencies

The updated and context-relevant competencies include several concepts that were not represented or emphasized within the previous version of Canada’s Home Health Nursing Competencies [39]. Many of these concepts align with increasing emphasis and international standards related to the provision of integrated and person-centered home care, which focuses on maintaining intrinsic capacity and is responsive to clients’ holistic needs and diverse backgrounds and contexts [49, 68, 69]. This is illustrated by competencies focused on using a strengths-based approach to support client self-determination and engagement in care, providing culturally safe and trauma-informed care, incorporating the social determinants of health into health assessment and care planning, and facilitating equitable care access, particularly among equity-deserving groups. Revised competencies also include three statements focused on Indigenous populations with direct reference to the Truth and Reconciliation Commission of Canada: Calls to Action [41], including recognizing Indigenous ways of knowing and the impacts of colonization. Another concept receiving greater attention in the revised competencies is the role of technology in the provision of care and the collection and use of data to support decision-making, reflecting the increasing digitalization of healthcare [46, 47, 70].

Language changes within the revised competencies highlight the importance of health equity for nursing practice and how terminology related to health equity has evolved. Terminology such as equity-deserving, cultural safety, and cultural humility were intentionally selected to align with health equity language recommendations [71, 72], which were not available when the original competencies were developed in 2010. Furthermore, language related to those who support home care clients has also been expanded, referring to clients’ broader social support network, rather than being limited to families and/or caregivers, recognizing the role of other individuals critical to supporting clients who may not be directly related or formally identified as “caregivers” [73, 74].

Competencies and workforce stabilization

Research shows that nurses transitioning to home health practice experience a significant learning curve due to the breadth of their role and the independent practice environment [34]. Therefore, ensuring that the health workforce is prepared and well equipped to meet population care needs in the home and community sectors is important [27]. The revised home health nursing competencies should be leveraged to support workforce stabilization and staff retention initiatives by improving alignment between home health nurses’ skills and knowledge and their expected daily practice demands. Given that revised competencies represent the knowledge, skills and attributes relevant and essential for delivery of safe and ethical nursing care in the present-day home health context [40], alignment of competency assessment and professional development opportunities with the updated competencies can support creation of targeted resources that facilitate necessary practice development. The provision of relevant education and training opportunities is a key strategy for building nurses’ skills and confidence and improving the quality of care [75], all of which are factors linked with nursing job satisfaction and retention [9, 76, 77].

New concepts within the revised competencies (e.g., cultural safety, Indigenous ways of knowing, and data-informed decision making) may be especially relevant topics for professional development opportunities, given that these competencies may not have been adequately addressed in practicing home health nurses’ education and training programs [78]. Our findings also reinforce previous research identifying both the provision of culturally safe care and the use of data/technology as high-priority learning needs among community nurses [79]. Additionally, the comments received within this study expressing anti-Indigenous racism echo findings from other healthcare settings concerning the structural nature of Indigenous-specific racism [80, 81]. This emphasizes the necessity for education and training and organizational initiatives focused on supporting the implementation of the Truth and Reconciliation Commission of Canada: Calls to Action within healthcare contexts, in addition to further consideration about actions needed to address systemic racism [82].

Organizational support is critical for ensuring the implementation of updated home health nursing competencies to guide nursing practice and ensure that professional development opportunities support capacity building [83, 84]. There are a number of identified barriers to nurses’ professional development, including a lack of time, often related to inadequate staffing levels and high workloads, as well as a lack of resources, such as funding to attend educational opportunities [75, 83, 84]. In previous research, home care nurses reported that workplace integrated training opportunities which enhance their skills and knowledge and build on initial orientation and preceptorship experiences, are desirable and represent an incentive to remain employed within an organization and the sector [85]. Recognizing the reality that resource constraints, both in the sector and in the system more broadly, can limit organizations’ ability to offer professional development and training opportunities, the revised competencies can be leveraged to intentionally target learning opportunities to the key skills required by the workforce, supporting both employee experience and improved client care [83, 84].

Furthermore, the revised home health nursing competencies can support the development and stabilization of the home health nursing workforce if adopted by educational institutions to guide community nursing curriculum improvements and align prelicensure education and training with home and community care sector practice realities. The emphasis on home and community care within nursing curricula has been declining [37] despite the growing demand for home and community care services [1, 86], and distinct skills are needed to provide home and community care [32,33,34]. Ensuring that home health nursing competencies are represented in nursing curricula through course content, the involvement of instructors with home health nursing backgrounds, and providing clinical experience opportunities in the home and community care sector can help ensure that nursing students are aware of opportunities within home health nursing and are prepared to work in this role [87].

Implementation of research recommendations by CHNC

The updated competencies generated through this study have been used by CHNC to release Canada’s 2024 Home Health Nursing Competencies [67]. Owing to the education needs expressed by home health nurses within this study and related work [88], CHNC has developed an open-access self-assessment resource based on the 2024 Home Health Nursing Competencies to support identification of professional development needs among home health nurses [67]. Self-assessment resources [67] can be used by home health nurses independently, and by organizations to support performance evaluations and identification of learning needs and priorities among their staff to support use of the competencies to inform workforce stabilization and capacity-building initiatives.

Limitations

Although valuable feedback related to improving readability and consolidating competencies was captured through qualitative feedback, these suggestions were not incorporated into the final competencies given the feasibility considerations to add additional survey rounds. Furthermore, while significant efforts have been made to support the broad consultation and engagement of diverse home health nurses and interdisciplinary home care team members from across Canada, the perspectives of some groups (e.g., those identifying as Indigenous or as a member of a visible minority, home health nurses from the territories and some provinces) have not been adequately represented. However, we see this work as iterative, requiring updates at a regular cadence to ensure continued relevance to a constantly changing field. We recommend that future work continue to refine and update these competencies and explore opportunities to engage home health nurses with the perspectives that were not represented in this study.

Conclusions

An updated set of 79 home health nursing competencies was developed using an eDelphi process and consultations to engage diverse home health nurses and interdisciplinary team members in the competency development process. The updated competency set reflects important contextual changes that have occurred since Canada’s Home Health Nursing Competencies were first released in 2010 [39], including recognizing the importance of culturally safe care, acknowledgement of Indigenous ways of knowing and the ongoing impacts of colonization, increased use of technology, and advancements related to health equity language. Future work to refine competencies through engagement of diverse home health nursing perspectives and to explore and evaluate strategies to support implementation and uptake of competencies in home and community care organizations and educational institutions will be critical to support stabilization of the home health workforce and future-focused capacity building.

Data availability

The data collected and analyzed during this study are available from the corresponding author upon reasonable request.

Abbreviations

CHNC:

Community Health Nurses of Canada

The Standards:

Canadian Community Health Nursing Standards of Practice

HHN Competencies:

Home Health Nursing Competencies

ACCORD:

Accurate COnsensus Reporting Document

AWG:

Advisory Working Group

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Acknowledgements

The authors would like to acknowledge the funding and in-kind resources of many people and organizations from coast to coast to coast. Special thanks to the Community Health Nurses of Canada for support of this project, our Project Steering Committee for their dedication and leadership, and our Advisory Work Group members, who provided relevant, meaningful and practical input from practice and operational perspectives. We would like to also thank Dr. Paul Holyoke for his insightful review and feedback during preparation of this manuscript. This work would not have been possible without the collaborative efforts of all those involved.

Funding

This study was funded by an unrestricted grant provided by SE Health to the SE Research Centre as part of the organization’s commitment to impact-oriented health services research as a recognized research institution, learning health system and social enterprise. The funder had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

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Authors and Affiliations

  1. SE Research Centre, SE Health, 90 Allstate Parkway, Suite 800, Markham, ON, L3R 6H3, Canada

    Margaret Saari, Chelsea Coumoundouros, John Tadeo & Justine Giosa

  2. Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada

    Margaret Saari

  3. Daphne Cockwell School of Nursing, Toronto Metropolitan University, Toronto, Canada

    Barbara Chyzzy

  4. School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Canada

    Melissa Northwood

  5. School of Public Health Sciences, University of Waterloo, Waterloo, Canada

    Justine Giosa

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  1. Margaret Saari
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  4. Barbara Chyzzy
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  5. Melissa Northwood
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  6. Justine Giosa
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Contributions

MS was responsible for conceptualization, methodology, data curation, formal analysis, investigation, supervision, validation, visualization, writing– original draft and review & editing. CC was responsible for data curation, formal analysis, investigation, project administration, validation, visualization, and writing–original draft and review & editing. JT was responsible for data curation, formal analysis, investigation, and writing–review & editing. BC was responsible for formal analysis and writing–review & editing. MN was responsible for formal analysis and writing–review & editing. JG was responsible for conceptualization, methodology, investigation, supervision, validation, funding acquisition, and writing– review & editing. All the authors reviewed and approved the final manuscript.

Corresponding author

Correspondence to Margaret Saari.

Ethics declarations

Ethics approval and consent to participate

Ethics approval for this study was obtained from the Southlake Regional Health Centre Research Ethics Board (REB #: S-035-2324). This study was conducted in accordance with the Declaration of Helsinki, and informed consent was obtained from all participants prior to data collection.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Saari, M., Coumoundouros, C., Tadeo, J. et al. Advancing home health nursing competencies in Canada to reflect a dynamic care environment and complex population health needs: a modified eDelphi study. BMC Nurs 24, 378 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-025-03045-5

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Keywords

BMC Nursing

ISSN: 1472-6955

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