Module NM2: Advanced Research Methods 1
Perceptions of Bahraini Registered Nurses on Continuing Formal Education: A Mixed Methods Study
A proposal submitted in part fulfillment of the MSc. Nursing, School of Nursing and Midwifery
MSc. Nursing 2012- 2013
Word Count: 4,400
Table of Contents
CHAPTER 1: INTRODUCTION AND LITERATURE REVIEW… 5
1.0 Introduction: 5
1.1 Background: 5
1.2 Significance of the Study: 7
1.3 Problem Statement: 7
1.4 Research Questions: 7
1.5 Aim of the Study: 8
1.6 Objectives of the Study: 8
1.7 Conceptual Framework: 8
1.8 Define Study Terms: 9
1.9 Search Terms: 9
1.10 Search Strategy. 9
1.10:1 Literature Review: 9
1.10.2 Motivator Factors. 10
1.10.3 Hygiene Factors: 11
1.10.4 Methodological Issues: 12
1.10.5 Summary: 12
CHAPTER 2: RESEARCH DESIGN.. 13
2.0 Introduction. 13
2.1 Study Hypothesis: 13
2.2 Research Methodology: 13
2.3 Population, Sample, and Sample Selection: 14
2.3.1 Inclusion Criteria: 15
2.3.2 Exclusion Criteria: 15
2.4 Study Setting: 15
2.5 Data Collection: 16
2.6 Data Analysis: 16
2.7 Pilot Test: 17
2.8 Reliability and Validity: 17
2.9 Ethical Considerations: 18
2.10 Limitations: 18
2.10.1 Timescale and Resources: 18
2.10.2 Conclusion: 18
CHAPTER 3: SUMMARY AND CONCLUSION.. 20
3.0 Introduction: 20
3.1 Implications: 20
3.2 Recommendations: 20
3.3 Conclusion: 21
Works Cited. 22
The quality of health care is an ongoing issue for all healthcare providers. Nurses comprise the largest section of the healthcare workforce in the acute and continuing care settings, suggesting that there is a great deal of benefit to be gained from nurses working to the best o their capacity. Different national governments realize the link between continuing education and professional development, and clinical governance/care quality. However, there are issues about engaging nurses in their own development and in on-going learning. This dissertation proposal suggests a mixed methods design utilizing a questionnaire with close-ended and some open-ended questions to identify the perceptions of Bahraini Registered Nurses towards continuing formal education. This would allow for the identification of optimal approaches to support and engagement of nurses to design courses, which meet their own needs and those of their profession.
CHAPTER 1: INTRODUCTION AND LITERATURE REVIEW
The World Health Report by the World Health Organization (WHO) states that the future of effective healthcare practice relies on optimization of human resources (WHO 2000). Employers must ensure professional development of nurses through higher education (Jooste 2005). Advancements in knowledge and technology might reduce relevance of initial education thus, compromising quality practice (DeLeskey and Fetzer 2007).
Nursing involves lifelong learning, and “there is no such thing as sufficient initial education” (Gopee 2001, P. 610). Nonetheless, different literature confirms nurses’ value for ongoing professional learning (Beatty 2000). Where “RNs are undereducated members of the health care team, when compared with physicians, social workers, physical therapists, pharmacists, and dieticians” (Donley and Flaherty 2002, p. 38), they should upgrade their education, considering their low rank in the healthcare hierarchy (Neese et al. 2007).
This dissertation will develop a study design to explore and quantify perceptions of Bahraini registered nurses (RNs) toward continuing formal education. The first chapter sets the study context, followed by a literature review, while the second chapter outlines the proposed methodology. The final chapter presents conclusions and reflections on the study design, raising critical questions about the research and its benefits and limitations.
Bahraini RNs could upgrade their education through diploma and master degree programs. Their minimum requirement is completion of diploma or degree, and passing licensure exam. In 1976, a school of nursing at College of Health Sciences (CHS) pioneered formal nursing education in Bahrain (College of Health Sciences 2011). Additionally, in October 2006, the School of Nursing at the Royal College of Surgeons in Ireland (RCSI)-Medical University of Bahrain (MUB) conducted its first students’ admission (Royal College of Surgeons in Ireland, Bahrain, 2013).
Unlike the UK and some USA states, educational upgrade is not mandatory for Bahraini RNs. Such irregularity marginalizes some nurses, especially those trained within the traditional non-university system (Hakesley-Brown 1999 Cited in: Joyce and Cowman (2007). The Ministry of Health (MOH) in Bahrain thus, attempts to encourage RNs upgrade their education, by funding them and employing general nurses and nurses with AND.
Donley and Flaherty (2002) argued that low-level education nurses cannot address complex nursing issues. Similarly, studies show that higher education for nurses lowers patient mortality (Aiken et al. 2003; Clarke and Aiken 2003; Curtin 2003; Estabrooks et al. 2005; Needleman et al 2002; Tourangeau et al. 2007). However, these studies lack applicability to different contexts, based on the geographical factor. Differences in medication errors exist between nurses with varying educational levels (Fagin 2001). Research by Nogueras (2006) on 908 RNs considered their commitment to nursing, and intent to quit nursing. Results showed that nurses with higher educational level exhibited higher commitment and did not intent quitting nursing. Similarly, Rambur et al. (2005) in their study found that nurses with a nursing degree had greater job satisfaction and lower job stress levels.
Nurses wishing to upgrade their education might be inconvenienced by unavailability of higher educational programmes and limited qualified staff (De Young et al. 2002). Therefore, this study will address Bahraini RNs’ perception of continuing formal education, and the educational barriers Bahraini RNs face. This might help to eliminate barriers and support working Bahraini RNs to foster such experiences.
1.2 Significance of the Study:
There are discrepancies in the global perception of nurses, and the demands placed upon them as professionals. Their professional status does not reflect their responsibility level. This might affect their job satisfaction adversely. In addition, while some countries might provide nurses with professional development opportunities, others might not. However, in Bahrain, since 2003 nurses have had the opportunity to upgrade their education through support of the government and their employers. However, the perception of Bahraini RNs towards continuing formal education and the barriers they experience, with regard to continuing formal education, is not yet studied, thus remains unknown. Therefore, this study is significant, as its findings will reveal the perceptions of Bahraini RNs on continuing formal education and identify barriers they experience in continuing formal education. The recommendations could benefit the nursing profession if educators and employers will use them to strategize support programmes for nurses, which will improve health care provision.
1.3 Problem Statement:
The nursing profession is yet to move “from an apprenticeship model of training to more academic and scientific models of higher education” (Peterson, 2004, p. 393). According to Scott (2004), traditional apprenticeship educational methods are inadequate, “because they are unable to address the increasing pace at which scientific knowledge is being produced and technical skills are being upgraded” (p. 394). To change the negative perceptions about nursing, the nursing education programs should embrace higher degrees. Thus, identification of Bahraini RNs’ perceptions of continuing formal education and barriers that hinder them from advanced education is vital.
1.4 Research Questions:
This research study seeks to answer the following questions:
- How do Bahraini RNs view continuing formal education?
- What are the barriers experienced by Bahraini RNs with regard to continuing formal education?
1.5 Aim of the Study:
This study aims at exploring Bahraini RNs perceptions on continuing formal education, and identifying barriers they experience in continuing education. The new knowledge gathered in this study will help to develop strategies by the nursing administration to promote the continuation of formal education for Bahraini RNs.
1.6 Objectives of the Study:
The objectives of this research will be to:
- Establish how Bahraini RNs view continuing formal education.
- Identify barriers to continuing formal education experienced by Bahraini RNs.
1.7 Conceptual Framework:
Herzberg’s theory of motivation will lay the foundation for the study (Herzberg 1959; Herzberg 1966). Herzberg (1959; 1966) studied factors affecting employee motivation. Herzberg (1959; 1966) argued that employee satisfaction is founded on rewards. These rewards might be extrinsic (external), including, salary and bonuses; or intrinsic (internal), relating to feelings of satisfaction, psychological and emotional factors (Herzberg 1959; 1966).
Like other reviewers of this theory, Sachau (2007) agrees that Herzberg’s theory is impeccable, but challenging, since motivator factors differ. Herzberg (1959; 1966) labeled it the motivation-hygiene theories, suggesting that motivator factors were different in nature to the hygiene factors. Herzberg suggested that negative themes associate with job dissatisfaction (Sachau 2007). Motivator factors increase productivity, but hygiene factors cause dissatisfaction (Sachau 2007). Therefore, this study will look at motivator and hygiene factors in relation to Bahraini RNs and their perceptions of continuing formal education, in order to suggest how such education could be used for job enrichment.
1.8 Define Study Terms:
It is important to define the variables and terms for clarity to the researcher and reader of the research report (Nieswiadomy 2010). A conceptual definition provides a concept with theoretical meaning (Burn and Grove 2009), while an operational definition indicates, how a variable will be observed or measured (Nieswiadomy, 2010).
1.9 Search Terms:
Search terms were defined as registered nurses, continuing education, continuing professional development, continuing formal education, advanced education, reasons, influences, factors, motivation, barriers, perceptions, and attitude.
1.10 Search Strategy
The literature was electronically searched using University library portal. Searches were through multiple combinations of terms. Inclusion criteria included English Language articles, research studies or research reviews, and other relevant articles. Only full text articles via the university’s standard subscription were retained. Articles were read first by title, for relevance, then those retrieved were reviewed by abstract. Those with abstracts that looked promising were retained and the full text accessed and read.
1.10:1 Literature Review:
A literature review summarizes and analyses relevant research and non-research literature on study topic (Hart 1998 Cited in Cronin et al. 2008). This clarifies which problems have been investigated, which require further investigation, and which have not been investigated (Burn and Grove, 2009). In conjunction with the terms used to search for articles (see search terms) related to continuing formal education, twelve articles that included continuing formal education to a baccalaureate degree and /or above were included. The following reviews of literatures are spotlighting the key words derived from the research question:
1.10.2 Motivator Factors
Literature addressing this issue is limited. Therefore, literature is adopted from non- peer reviewed studies. Richards (2010) explored the perceptions of 40 RNs, to continuing professional development, using a quantitative design. Reduction of stress levels and empowerment, were identified as factors, which motivated nurses to engage in continuing formal education. Knowledge and leadership capacity development, increased practice quality, and long-term career planning, are other factors (Richards 2010). This study was conducted in South Africa, thus, has limited applicability.
Mangubat (2005) carried out a mixed method study with a convenience sample of 120 RNs in the USA using a survey design. Research questions were quantitative and open ended in nature. Findings showed that nurses were motivated to upgrade their education, by their learning and goal orientation. Learning orientation relates to self- motivation to learn, while goal orientation relates to personal gains and achievement (Mangubat 2005). Results showed that learning orientation scores were higher. Nonetheless, different cultural and professional contexts limit this study’s applicability.
Hughes (2005) conducted a mixed method study to explore nurses’ perception of the value of CPD and to analyze the factors influencing those perceptions and identify barriers to successful CPD. Questionnaires were distributed for a convenience sample of 200 nurses, followed by interviews of eight self-selecting respondents. Hughes (2005) found that managers’ leadership style and their responsiveness to change were the influencing factors. Joyce and Cowman (2007) conducted a mixed method study to explore reasons for participation in post-registration education. The convenience sample was nurse students in a one-level institution in Ireland. 243 questionnaires were returned representing 46.7% response rate. The major reason for participation in post-registration education was to “obtain promotion to a higher grade” (99%) and to “enable me to extend my clinical role” (98%). A qualitative study in a South African university showed that other factors included empowerment, promotion, and educational and professional development (Jooste (2005). Watson (2004) suggests that nurses will engage in learning for capacity advancement, compliance with regulatory mandates, and for quality practice.
1.10.3 Hygiene Factors:
Richards (2010) identified lack of role models, lack of support from management, and staff shortages, as hygiene factors of continuing education. Mangubat (2005) suggested that contextual barriers acted as hygiene forces, including home life and family responsibilities. Root (1991) in a study in Indiana, USA identified hygiene factors as lack of recognition of work experience, repetition of previous learning, lack of reward, and poor scheduling.
In a cross sectional study, Turner (2003) identified institutional, dispositional, and situational hygiene factors. Situational factors include time, home, and job responsibilities, and lack of study resources (Turner 2003). Dispositional factors were lack of energy, previous low educational achievement, fear of seeming ambitious, and not wanting to study full time. Institutional factors included study completion time, attendance requirements, and administrative issues (Turner 2003).
Adelman (2002) conducted a survey of three hundred and six nurses in the USA, and found that the longer a nurse had been qualified, the less likely they were to gain transferable credits for their previous work, resulting in course and study repetition, which limits motivation. In a small scale qualitative study, which compared standard, class-based education with an online distance learning programme, Brown (2005) found that both cohorts had similar issues, including work balance, and lack of family support. Altmann (2012) identified appropriateness of the educational provision as a hygiene factor. Blythe (2008) suggested a further barrier was a lack of appropriate wage increase following further study.
1.10.4 Methodological Issues:
There are similarities in the 13 studies reviewed, with regard to instruments used, sampling method and size, and type, and size of location studies (See Appendix for Literature Review Framework). The common data collection instrument was surveys (N= 8) which was analyzed statistically. In two studies (Hughes 2005, and Root 1991) follow up interviews were conducted to validate findings. Instruments were pilot tested in and reliability and validity were reported and appeared satisfactory.
Similarity of designs was also related to the sample. All quantitative studies utilized a convenience sample, while sampling was purposive for all qualitative study. Sample size for quantitative studies varied from 40 to 878 respondents. In qualitative studies, the sample size ranged from four to 250 participants. Finally, in mixed methodology, the sample size ranged from 120 to 243.
Most studies were completed in small geographical locations (Richards 2007, Bellfield and Gessner 2012, Adelman 2002, Altmann 2012, and Joyce and Cowman 2007). For example, ten studies were conducted in USA, two in South Africa, and one in UK and Ireland. This confirms interest and currency of the topic in many countries.
It is evident that there are a number of motivator and hygiene factors influencing motivation to engage in continuing formal education. However, studies identifying barriers are more prevalent, and those identifying motivator factors also identified considerable hygiene factors. Literature is limited to dissertations and theses for the most part, mostly carried out in specific regional contexts. The proposed methodology will be explored in the next section.
CHAPTER 2: RESEARCH DESIGN
The quality of the study design is the key to the quality and usefulness of the study findings (Bryman 2008). This chapter will outline the processes involved in the study and the key stages of the research process. The researcher will focus on identifying Bahraini RNs view of continuing education and the barriers that hinders them from continuing their formal education.
2.1 Study Hypothesis:
Hypothesis is the formal statement of the expected relationship between two or more variables in a specific population (Burn and Grove 2009). Since this is not an experimental study, there is no hypothesis. Please refer to the research aims and objectives in Chapter One.
2.2 Research Methodology:
The selection of methods and their application are always dependent on the aim and objectives of the study, the nature of the phenomenon under investigation, and the underlying theory or expectation of the investigator (Babbie and Mouton, 2002). Thus after reviewing most of the literature, a mixed methods study will be adopted to optimize the research findings. Additionally, a descriptive survey research will be adopted, as well as the questionnaire for the data collection. This study will allow respondents to voice their additional comments, by assuming open-ended questions. Therefore, the data generated will be qualitative. By using descriptive qualitative findings, which are analysed by SPSS, together with a small-scale qualitative study, the researcher ensure a maximum use of quantitative methods, which will also allow a deeper study of the perceptions of nurses, by use of qualitative research (Creswell, 2009). The advantage of mixed methods approach adopted by this study is that it is highly effective, since it allows for the quantification of perceptions, as well as identification of perceptions of the respondents, which were previously not recorded (Bryman, 2008). Similarly, De Vaus (2001) noted that this method results in high-quality findings, and allows for a wider scope of results. According to (Blaikie, 2000), are more capable of developing “theoretical argument for the social phenomena under consideration” (p 24-25).
2.3 Population, Sample, and Sample Selection:
Population refers to the entire element that meets certain criteria for inclusion in a given universe (Kerlinger and Lee 2000 cited in Burn and Grove 2009). However, it is not possible to survey an entire population, i.e., every Bahraini RN, and therefore, a sample which is usually a subgroup of the population should be used (Burn and Grove 2009).The sample is chosen to represent the population and is used to make generalization about the population (Nieswiadomy 2010).
Convenience sampling, which is also referred to as accidental or incidental sampling, will be employed in this study. This involves choosing readily available people or objects for a study (Nieswiadomy 2010). These elements may or may not be typical of the population and are chosen to save time and money. In addition, there is no accurate way to determine their representativeness (Burn and Grove 2009).
A total of 210 Bahraini RNs from primary, secondary, and tertiary level who are currently continuing their formal education (RN-BSN Bridging program, Specialty RN Diplomas, and Master degree) at two Nursing Schools in Bahrain will be invited to participate in this study. Selection of these two nursing schools is based on the notion that the researcher would have easy access to the sample during the study periods. In addition, a convenience sample of Bahraini RNs from primary, secondary, and tertiary level who are not currently undertaking continuing formal education will be invited to participate (A statistician will be consulted to approve the sample size). The purpose of selecting this sample is to obtain descriptions that would accurately portray the characteristics of the total population Bahraini RNs working at health institutions in Bahrain.
2.3.1 Inclusion Criteria:
Inclusion criteria for participation in this study will be as follows:
- Bahraini RNs currently continuing their formal education at two nursing schools in Bahrain
- Bahraini RNs from primary, secondary and tertiary level who are not currently undertaking continuing formal education
- Willingness to participate
2.3.2 Exclusion Criteria:
Exclusion criteria will include:
- Bahraini RNs who are currently continuing their formal education in other nursing schools in Bahrain or in other countries
- Not willing to participate
- Non-Bahraini registered nurses who will be continuing their formal education in the two nursing schools at Bahrain.
2.4 Study Setting:
The study setting will be the two main Nursing Schools in Bahrain, in addition to a public multispecialty Secondary and Tertiary Care Health Facility that provides Emergency, Outpatient and Inpatient Care to all Citizens and Residents of Bahrain. Moreover, 25 Primary Health Care Services will be included.
Bahraini RNs who are currently studying will be accessed through Research and Ethical Committee of both Universities (Appendix 3).Whereas Bahraini RNs from primary, secondary, and tertiary level who are not currently undertaking continuing formal education will be accessed through gaining approval from Health Research Committee at MOH (Appendix 4).
2.5 Data Collection:
Data collection is a key determinant of the quality of a study, and this is based on the right research tool (Bryman 2008). In this study, the tool developed by Richards (2010) will be adopted, as it is pre-tested. Additionally, the survey method used by (Richards 2010) will enable the researcher to ask Bahraini RNs questions in a written questionnaire about their view of continuing formal education and perceived barriers to continuing formal education. Permission was taken from the author through email and Richard sent the original questionnaire to the researcher (Appendix 5). The researcher will distribute the questionnaires. The participants will be instructed to place their questionnaires after completion in a sealed envelope. Envelops will later be collected by the researcher.
The instrument consists of sixty-four close-ended questions with Likert Scale, a format in which the respondents are asked to indicate on a four-point scale: strongly agree/ agree/ disagree/ strongly disagree. In addition to four open-ended questions related to the preceding closed questions (Appendix 6). The questionnaire is divided into the following sections: demographic information on the sample, demographic information relating to continuing formal education, views on continuing professional development, motivations to engage in continuing formal education, and barriers to undertaking continuing formal education. The completion of the questionnaire will take approximately 20-30 minutes (Appendix 6)
2.6 Data Analysis:
Descriptive statistics allow for the quantification of answers and identification of trends and weight of opinion. They also allow for a limited number of relationships between variables to be identified, even if these are not inferential (Polit and Beck 2008). In order to ensure quality in analysis, SPSS (version 20) will be used, utilising relevant tests depending on the variables in the study instrument.
The data, which will be obtained in response to the open-ended questions, will be analysed, to identify emerging patterns from the responses that will be obtained, then the responses will be interpreted in term of the specific context in which the questions are asked.
2.7 Pilot Test:
A pilot study is a smaller version of a proposal study (Burn and Grove 2009). This will be conducted to determine the feasibility of the proposal, identify problems with the study design, and determine whether the sampling is representative and effective, to examine the reliability and validity of the research instrument, and to refine the data collection and analysis plan (Burn and Grove 2009). As the instrument, which will be used, will be modified, therefore, a pilot test will be done on five Bahraini RNs currently continuing their formal education at two nursing schools in Bahrain, and five Bahraini RNs from primary, secondary and tertiary level who are not currently undertaking continuing formal education (A statistician will be consulted to approve the pilot size). The Bahraini RNs will be asked to respond to all questions, marking those that may be difficult or confusing. Thus, the questions will be modified based on the feedback that the RNs will provide.
2.8 Reliability and Validity:
Reliability is concerned with the application of a particular technique, which if applied repeatedly to the same object, would yield the same result each time (Nieswiadomy 2010). It is concerned with the consistency, stability, and repeatability of the research participants’ responses as well as the researcher’s ability to collect and record information precisely (Babbie and Mouton 2002), while validity is concerned with the instrument’s, ability to gather the intended data. The content of the instrument is important in validity testing (Nieswiadomy 2010). When asking how valid the measuring instrument is, face/content validity is one of the criteria regarding the researcher’s success in making appropriate measurement. Face/ content validity asks whether there is agreement concerning the concepts in the data collection instrument (Babbie and Mouton 2029). Richards (2010) enhanced the face/content validity of the instrument by requesting one of the respondents in the pre-test to assess the data collection instrument by filling in an assessment form (Appendix 7). The researcher will measure the validity and reliability of the instrument using the pilot study and SPSS program.
2.9 Ethical Considerations:
All research must be carried out within fundamental ethical codes, including the Declaration of Helsinki and the Nuremberg Code (1964). These include beneficence/non-maleficence, autonomy, and informed consent (Polit and Beck 2006). In this case, a full information sheet and consent from will be availed to all participants (appendix 8). All participant data will be kept anonymous. The participants will be informed that they have the right to withdraw from the study at any time. The researcher will report the findings of the study to the participants upon completion of the study. Ethical approval will be sought and gained from the institutional research ethics committee (Appendix 3 and 4).
The limitations of this study include the relative inexperience of the researcher, the limitation of the study design to collecting descriptive statistics, the respondent rate of the participants, and the focus on only one country (Bahrain).
2.10.1 Timescale and Resources:
Please refer to Appendices
A quantitative, descriptive, exploratory design adopting a questionnaire to collect the data will be used to conduct this research study. Data will be collected via a pre-tested instrument. A convenient sample consisting of Bahraini RNs will be drawn from two nursing schools in Bahrain, besides Bahraini RNs from primary, secondary, and tertiary level who are not currently undertaking continuing formal education. Study setting, data analysis methods, pilot study, suspected limitations, timeline with recourses and ethical consideration pertaining to the study were discussed.
CHAPTER 3: SUMMARY AND CONCLUSION
This study will examine the perceptions of nurses towards continuing formal education. The main aim of this study is to identify the different motivator factors, and the various hygiene factors, which determine whether RNs in Bahrain will engage in continued formal education, and whether if they do, they are likely to succeed or not.
The major implications of this study concern employers in the health care agencies. This research will enable employers to be in a position to identify and understand major factors in the organization, which serve as a hindrance to the professional advancement of RNs. These will also understand the factors, which serve as a source of motivation to the nurses, and which are most likely to make them upgrade their education. This research will also have important influence on the educational providers. They will be in a position to identify and understand important factors relating to design, delivery, fees, funding, communication, duration, and nature of courses. This will allow them to tailor such courses to meet the needs of prospective students.
This study should be viewed as one stage in a much larger drive towards the professionalization of nursing practice within Bahrain, and throughout the whole world. It is clear that a lack of recognition of the capabilities of the nursing workforce could have a detrimental impact on the efficiency and quality of the healthcare services provided. Therefore, in order for important positive changes to be made in the health care practice to improve the efficiency and quality of services, it is important to identify factors, which will motivate nurses to return to education. Education and continuing professional development is known to have positive effects on the nursing practice. This will also have the capability of increasing the motivation of nurses and enhancing their performance in their job roles.
This proposal outlines a way forward to identify key information about continuing formal education for Bahraini RNs. It is however only one study, since it is conducted in Bahrain only. It should therefore, be seen in this context. However, this study and its findings should serve as a means of opening a window for deeply understanding the various complex factors, which would motivate nurses to perform effectively, and to even enhance that performance more, through continuing professional development.
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