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Question:
Aims:
1. To investigate the experience and perception of nursing education undertaken in India and the UK on nurses personal and professional lives in relation to health promotion.
2. To assess the impact of studying in the UK and an Indian environment on developing professional nursing practice and health promoting skills and knowledge.
3. To find out how these education and training pathways contribute to promoting individual health and improved practice.
4. How this training enhances the nurses? personal development and skills.
Answer:
Title: What is the impact of the nursing education and professional nursing qualification gained through study in India and UK? A Health Promotion perspective
Abstract
This paper employed the phenomenological approach, in which the views of ten graduate nurses were sought regarding their experience and perception of nursing education undertaken in India and in the UK. In the semi-structured interviews, focus was on assessment of the impact of studying in the UK and Indian environment on key public health issues, namely: personal and professional nursing practice, health promotion skills, and knowledge. The researcher used qualitative analysis of the interview transcripts to find out how this education and training contributes to the promotion of both individual health and improved practice. Insights were also sought regarding what the nurses think about the impact of nursing training on their personal and professional development and skills.
An overwhelmingly high percentage of the interviewees exhibited a positive appraisal of the training they gained in India and the UK. They also affirmed the need for nurses to seek higher education, to adapt to cross-cultural challenges, and understand their roles as health promoters. As health promoters, nurses understood that the community expects to be critical thinkers and to be able to exhibit health awareness at both personal and family level. The study also highlighted the need for nurses to be accorded opportunities for seeking higher education for them to be able fulfil their professional goals and to play crucial roles relating to health promotion.
Contents
Health promotion and Nursing. 5
Chapter 2: Literature review.. 9
Search strategy: Inclusion and Exclusion Criteria. 9
Health promotion in nursing. 9
Nursing education and health promotion. 10
Impact of bachelor degree in nursing on nursing profession. 15
Impact of nursing education on personal and professional lives. 17
Benefits of international education and career development 19
Chapter Three: Methodology. 21
Semi- structured interviews. 28
Ethical and Governance issues. 32
Experience and perception of nursing education among nurses. 45
The impact of studying in foreign environments. 46
Contribution of education in improvement of interviewees’ practice. 47
Nursing training: a way of enhancing nurses’ personal development and skills. 49
Chapter 6: Recommendations. 52
Chapter 1: Introduction
Overview
Health promotion is widely accepted as a part of any nursing education programme. Nurses within education, practice and research settings can participate in the advancement of health promotion. They must have the understanding of evidence-based practice and analysis of the situation to enhance health promoting skills and behaviour in nursing practice as well as be able to communicate this understanding to the public at large. In addition, this leads to awareness among nurses on the need for the public to understand their own health status, the health of their families, and the overall health of the population.
I have chosen this topic because I want to cultivate a report on the impact of nursing education on the lived experience of nurse’s personal and professional lives in relation to health promotion. There is lack of research in this area about how the health promotion is useful in their personal and professional life and what efforts are required to improve the understanding to become a superior professional. Individuals get admission in nursing field to gain nursing qualification so they can have secure job value, income and good status in community. Moreover, the knowledge and understanding that they attain through nursing is useful and helpful for their personal or day-to-day life.
Nursing: an introduction
Nursing is a unique health care profession whose main aim is to promote health and well-being at individual, community and population levels. An estimated 35 million nurses and midwives form the vast part of the health services (WHO, 2007). A career in nursing gives the individual plenty of scope and provides an environment which is interesting, rewarding and challenging. Nursing plays an important role in improving the health of the public because they are health professionals who most often come into close contact with vulnerable patients.
Health promotion and Nursing
Healy and Sherry (2010, p. 39) observe that nurses comprise the largest health professional group. They are viewed as fundamental in achieving the goal of primary care strategy. Nurse’s accountability in improving public health arises out of their educational status and the access that they have to the community in the course of their efforts to provide health related activities. Moreover, WHO (2003) indicates that the role of nurses in health promotion is broadly known internationally. Meanwhile, it is suggested that of all healthcare professionals, nurses have the highest degree of visibility and credibility within the community. The World Health Organisation notes that nurses are high in demand mainly owing to their positions as leaders in health promotion. The WHO made this observation against the backdrop of the plan dubbed Health for All 2000 (Gott and O’Brien, 1990, p. 41). Nevertheless, the role of nurses in promoting health and wellbeing of individual is well defined in contemporary nursing and public health literature. A number of studies suggest that there is a growing interest in health promotion and health education within the nursing practice (Kwong and Kwan 2007, p. 50).
Moreover, the continued demand for nurses remains a priority issue within health care sectors continuously worldwide. WHO (2009) suggests that the existing global standards for initial education on nursing and midwifery help to strengthen health systems to meet population needs and protect the public. These standards have been properly maintained in, among other countries, India and the UK. These two countries are known to produce highly educated nursing professionals who contribute positively on the development of nursing professional practice. During the 20th century, nursing professionalization in the west encouraged international nurses to pursue higher levels of qualifications so as to ensure progress in their careers (Raholam, 2010, p. 313).
The rationale for choosing this topic is that as nursing is the vital part of the public health and health care sector. Without nurses health sector can’t work effectively, they are not just helping for prevention and treatment of disease, in addition they helps in health promotion and quality care to save lives (WHO, 2007). Therefore, the main focus of this dissertation is to provide a qualitative research report on the impact of nursing education and post-registration professional studies in nursing on the development of their personal and professional lives as well as practice of nurses in terms of improving practice and promoting health. Issues on the importance of nursing diploma and of international higher education, as well as debates surrounding the impact of basic nursing training and professional nursing education on nurse’s professional and personal lives will also be explored.
Research Question This exploratory study is aimed at answering the research question:
What is the impact of the nursing education and professional nursing qualifications, from the health promotion perspective, gained through study in India and UK (a) on nurses’ personal lives (wellbeing, awareness and economic aspects) and (b) on the development of professional practice (confidence, skills, health promotion skills and knowledge)?
Aims and objectives
Aims:
- To investigate the experience and perception of nursing education undertaken in India and the UK on nurses personal and professional lives in relation to health promotion.
- To assess the impact of studying in the UK and in an Indian environment on developing professional nursing practice and health promoting skills and knowledge.
- To find out how these education and training pathways contribute to promoting individual health and improved practice.
- To determine how this training enhances the nurses’ personal development and skills.
Objectives:
- To appraise the nursing education and qualification literature review to identify the current state of knowledge relating to impact of experience of nursing qualification on nursing professional practice in terms of health promotion and improved nursing practice and on personal life.
- To survey three cohorts of Indian nursing students (those having a nursing diploma from India and one year top up UK graduate degree (professional studies in nursing) from the University of the West of England, Bristol to explore the impact of the nursing qualification (gained through study in India and UK) on their personal and professional lives and on their health promotion and improved practice.
- To recruit a sample of up to 10 Indian international post graduate nurses students of different cohorts to organise the individual semi-structured interviews to gain in-depth knowledge of experience.
- To gather the primary data by answering the research question through interviews and questionnaire.
- To produce an original research report documenting the research aims, methods, findings and recommendations for academic inquiry and assessment in consideration of a master’s degree award.
- To confirm the research findings within the nurses professional experience and the impact of experience in their future career.
- To disseminate research findings appropriately.
Statement for research
Despite the large section of registered nurses from India involved in improving practice and health promoting activities in their home country and in higher education in the UK to date, there is a lack of research studies exploring the effects of nursing education with reference to health promotion, improve practice and higher education on nurses personal and professional lives. This study seeks to develop a comprehensive understanding of Indian nurses life experience in nursing diploma and professional study abroad. This understanding will be achieved through accounts of their experience in their own words.
Chapter 2: Literature review
Search strategy: Inclusion and Exclusion Criteria
Before emphasizing any more on the research question, it is necessary to explore the available literature. With regard to health promotion in nursing, much has been documented. An analysis of this literature is essential in the understanding of what is already known, the gaps that exist in literature, as well as trends among researchers. For this reason, a systematic search of literature was undertaken. The researcher used the electronic databases of the University library. The British Nursing Index (BNI) was used via EBSCO for its nurse focus. Others included the Excerpta Medical Database (EMBASE) and Psychology Information (PSYCINFO) via OVID, and Cochrane Library.
Some of the search terms used include (in terms of categories): nursing student, nursing graduate (population), nursing education, nursing curriculum (exposure), health and wellbeing, awareness, attitude (personal outcomes), and professional, practical development (professional outcomes). In terms of perspective, some of the search terms that were used include: health promotion, community hospital, international training, and education experience.
Health promotion in nursing
There is much literature on health promotion in nursing, the role of education in nursing, and the role that nurses play in public health. There is no doubt that upon gaining the necessary academic qualifications, nurses become more aware of their own health as well as of family health. As Rush (2010, p. 814) observes, nurses have historically been expected to act as role models in health promotion. In a related study, Piper (2006, p. 102) focused on health education and the practice of health promotion in the UK, and the way these aspects fit in with the established language and theory. In this qualitative investigation, Piper (2006) noted that various models of practice have been subjected to considerable debate in literature.
In other areas of health promotion literature, focus is on the extent to which nurses appreciate their role as role models for health promotion. For instance, Rush (2005, p. 169) used semi-structured interviews and focus groups with nurses working in different settings.
Nurses commonly perceive that the society expects them to act as role models, to act as informational resources, and to always practice what they preach. However, they way these nurses define themselves remains independent of social expectations if their personal and professional domains are anything to go by (Rush 2005, p. 173). At the personal domain, they are seen to accept imperfections, and to maintain self-reflection. At the professional domain, they are seen to gain trust, to be caring, and to be pursuers of partnerships.
Whitehead (2010, p. 259) found out that nursing has not yet contextualized and differentiated health education and health education, health promotion, as well as specific roles and functions of nursing. Whitehead also noted that that nursing-related clinical practice has not yet reflected universally the language and theory of ‘general’ health promotion. Similarly, nursing is yet to demonstrate a clearly notable far-reaching health policy cum political role in the formulation and implementation of health promotion agendas. This state of affairs has continued to exist for some time now.
Nursing education and health promotion
Nursing training typically combines both theory and practice. During the training period, students receive practical instructions from senior ward staff. Organization and supervision of their work is done by nurse-tutors. The students also attend lectures conducted by specialists in different fields of medicine. In some days, study sessions and lectures may be devoted to various aspects of nursing and medicine.
Other than the conventional training, reflexive learning is also necessary for nurses. Liimatainen (2001, p. 1132) notes that this type of learning develops in the context of both health promotion and health counselling, both tasks of which take place during specialized nursing education. In a follow-up study of some 16 Finnish nursing students undertaking a 3-year course, the participants’ level of reflexivity was analyzed during videotaped counselling sessions. In the further exploration of their qualitative features in reflexive counselling learning process, focus was on contexts relating to health promotion. Liimatainen (2001, p. 1132) found out that half of the students under study attained the level of critical consciousness in the course of their nursing education. All the others hovered around the level of consciousness. Some two students who had represented thoughtful action with no reflection during the first year of study managed to reach reflection and at one point, even critical reflection at the advanced stages of their education. These findings are of great importance for someone interested in the empowerment approach in the understanding of health promotion in nursing. The indication of these results is that if nurses are to use the empowerment approach in health promotion, they have to learn the art of critical reflection (Liimatainen 2001, p. 1181).
The debate on empowerment is one that recurs whenever there is a talk on education. The same case applies in nursing education and health promotion efforts. As Kumar (2009, p.175) notes, nurses and midwives play a critical role in both community education and health promotion. In this regard, their main role, according to Kumar, entails prevention of diseases, rehabilitation, and nursing therapeutics. In his paper, Kumar (2009, p. 178) seeks to identify the various ways in which nurses and midwives can contribute to better health care in community. Among the suggestions that Kumar (2009, p. 182) makes is ensuring that manpower planning and development is made an integral element of human resource planning in all Indian health systems. Secondly, Kumar recommends that a study on nursing manpower needs to be undertaken that focuses on manpower planning, with specific areas being projections on needs, deployment, and utilization in response to changes in the country’s healthcare reforms.
However, policy setbacks are not all there is in terms of challenging facing nursing education and health promotion. In the view of Liimatainen & Poskiparta (2001, p. 34), student nurses’ constructions of health promotion is also worth investigating. Liimatainen & Poskparta analyze the nursing in two Finnish polytechnics. Thematic analysis of the views showed that in the course of the first year, the construction of health promotion among 13 years changed. Moreover, six students who had broad constructions regarding health promotion changed their views. In the changes, the emphasis changed from physical issues to multidimensional health promotion, the health promotion became much more contextual and concrete, and the conception of one’s perfect health became much more relative and permissive. Moreover, the interpretation of health promotion was viewed to shift towards maintaining dedication to the patient. On the basis of these findings, Liimatainen & Poskiparta (2001, p. 43) concluded that major challenges in nursing education need to be addressed, particularly the promotion of learning from a constructivist perspective.
According to Clark & Maben (1998, p. 186), the new UK’s approach to education on pre-registration nursing, so-called Project 2000, has both an overt focus and a specific remit for preparing nurses for the key role of health promoters. Clark & Maben (1998, p. 172) went as far as to report data that illuminated the understanding of Project 2000 students regarding concepts of health education and health promotion. The data was also used to indicate the extent to which qualified nurses within the new approach perceive themselves in terms of preparedness to the health promotion role. Clark & Maben (1998) found out that students appear confused regarding the terms ‘health promotion’ and ‘health education’, even though most of them feel that a clear distinction exists between these two concepts. For most of the students who went through the Project 2000 approach, the descriptions offered emphasize on individualistic approaches as well as behaviour and lifestyle changes.
On a paradoxical note, however, Clark & Maben (1998) notes that both Project 2000 qualified nurses and students exhibit a clear understanding of the highly complex issues surrounding the conceptions of health promotion while at the same time remaining rather confused by this terminology and the way it relates to practice.
In recent years, the agenda on the provision of health services has been moving towards the broader context of promoting health and preventing disease in the first place instead of focus on patient care in the hospitals (WHO 2007, p. 100). The World Health Organisation (WHO) plays an eminent role for setting the broader agenda for health promotion (Naidoo and Wills 2009, p. 119). According to Naidoo and Wills (2009, p. 119), the term health promotion includes the various interventions for achieving the overall health and well being through promoting healthy lifestyles, encouragement of access to services and involvement in health decisions. The ultimate aim is to create a supportive environment in which the healthy choices become the best options in the provision of health education (Naidoo and Wills 2009, p. 48). It has already been established that political and government policy initiatives cannot work effectively until people are able to take more control over their own health by enhancing awareness, knowledge and strengthening community action.
In India, the role of nurses in health promotion has been recognized as much as in the UK. The same case applies to issues of nurses’ personal and professional development as well as experiences and perceptions towards nursing education. However, as it to be expected, every researcher adopts a rather unique approach when addressing specific aspects of nursing, education, and personal and professional development. For instance, Dicicco-Bloom (2004, p. 28) described the experiences of immigrant women nurses regarding their work and life within a cultural setting (United States) that is different from their own (Kerala, India). Semi-structured interviews were carried out on nurses who were born and brought up in Kerala India but were working as nurses in the US. The study underscored the prevailing inequalities within the US healthcare system. In this case, the challenge identified was that of establishing a just and effective environment for the providers (in this case nurses) as well as recipients of healthcare. Velayudhan’s (2004, p. 57) aim, on the other hand, was to specifically introduce palliative care into the undergraduate nursing and medical education, as well as ascertaining whether such education improved the knowledge of students on palliative care. Surprisingly, Velayudhan (2004, p. 62) found no lasting improvement in knowledge scores of different groups of students. Velayudhan (2004, p. 62) concluded that although inclusion of palliative care within the Indian undergraduate teaching curriculum is feasible, thought should be given to the teaching methods, curriculum content, and evaluation techniques.
Regarding nursing education in the UK, Woods (1997, p. 823) refers to the Florence Nightingale Scholarship to Canada and the USA in considering a number of issues that UK curriculum designers might want to consider when developing clinically-based advanced programs for nurses. In efforts to understand advanced nursing roles in the UK better, Woods (1997, p. 826) feels that advanced-role terminology such as ‘clinical nurse specialist’, ‘nurse practitioner’, ‘nurse clinician’, and ‘nurse consultant’ should be clearly defined. This, according to Woods, would go a long way in disentangling various advanced-practice roles. At the advanced level, issues of both ‘generalist’ and ‘specialist’ practice model should also be discussed (Woods 1997, p. 829). Woods asserts that the UK has a unique opportunity of establishing an advanced nursing system on a collaborative basis as a way of integrating key nursing-related concepts into clinical practice.
Nandan (2007, p. 233) on the other hand, is interested in India’s public health, specifically the issues and challenges relating to human resources in the sector. Nandan notes that since India’s independence, many concerted efforts have been made to address the rising need for human resources in the country’s health sector. However, to this day, there is still shortage in all human resource categories in the public health sector. For this reason, Nandan argues that it is important for the Indian government to establish a link between training policy and National Rural Health Mission in efforts to achieve human resource goals, especially with regard to health promotion and education.
Impact of bachelor degree in nursing on nursing profession
In the 1980s and 1990s, there was a positive change in nursing education globally due to healthcare reforms (Lusk, Russell, Rodgers and Wilson- Barnett 2001). For instance, in the UK-based National Health Policy (NHP) there is emphasis on the need to prepare nurses to function in super-speciality areas required in tertiary care institutions, entrusting some limited public health functions to nurses after providing adequate training, and increase the ratio of degree holding versus diploma holding nurses (Kumar 2005, p. 88). On the other hand, the Indian nursing council also supported that the view that BSc Nursing degree programmes are capable of meeting the changing needs of the society and to meet future challenges effectively (Kumar 2005).
According to Mahaffey (2002, p. 32), many international studies support the view that nursing personnel with bachelor and masters degree qualifications are not only more competent in their practice, but they also raise the standard and status of nurses and nursing profession. This evidence is also provided by Phillips, et al (2002, p. 39) in a study of RN and BSN graduates between 1995 and 1998. The study by Phillips, et al (2002, p. 39) showed that students demonstrated higher competency with regard to nursing practice, leadership, professional integration, research evaluation, and communication. They also showed that the quality of nursing education shapes the workforce in way that best meets the needs of the population. The need and importance of Evidence Based Practice (EBP) in nursing profession has been illustrated by different scholars and organisations (Norman et al, 2005, Kumar 2005, AACN 2010). EBP enables nurses to found best way of doing practice in clinical and community setting.
According to Skar (2010, p. 291), professional learning brings about critical thinking and analytical thinking skills in one’s professional life. These skills extend beyond the basic knowledge gained through nursing course. Some authors have already established a clear link between the higher levels of nursing education and improved patient outcomes (Aiken et al 2003, p. 24, Cooley 2005, p. 83, Gijbels 2010, p. 104). The American Association of Colleges of Nursing (AACN) (2010, p. 6) reported similar findings with the observation that graduates level programs have significant impact on the knowledge and competencies of nurses.
Johnson (1988, p.49) suggested that self confidence, communication and problem solving skills are also developed in the degree level nurses during educational training. To support this argument Giger and Davidhizar (1990, p. 101) talked about the ability by nurses to make diagnoses and critical evaluation of the intervention being proof of their competency and confidence level in different clinical and community settings.
The importance of degree holder nurses in better health outcomes as compared to diploma level nurses has been seen in various research studies (AACN 2010, p. 5, Cooley 2005, p. 91, Kumar 2005, p. 82). Furthermore, literature shows that developed countries such as UK, USA, and Canada are moving from basic nursing education towards the baccalaureate degree education as a minimum requirement for entry into professional nursing practice. On the other hand, Thailand, Australian, and New Zealand nursing education programmes are already based on bachelor degree level (ANMC 2007, p. 92). Eventually, nursing education is moving towards a level whereby PhD levels constitute an integral part of its curriculum (AACN 2010, p. 5). In essence, this is an encouragement to political leaders, policy makers, private organisations and nursing educational programmes to address issues relating to ways of improving the quality of nursing education that is offered at higher academic levels.
Impact of nursing education on personal and professional lives
Nursing education often portends considerable positive effects on the knowledge and competencies of the nurse as well as on wider range of the population (AACN 2010). According to Feinstein et al (2006, p. 50), there is sufficient evidence that education across the world is strongly linked to health and to determinants of health such as risky contexts, health behaviours, and preventive service use. This type of education remains part and parcel of individual’s life. Thus, in the same way, nursing education and practice has a significant effect on the nurses’ personal and professional lives (Cooley, 2008, p. 210). In a national survey of 496 American nursing students, Norman et al (2005, p. 117) reported that the participant viewed that nursing education and profession as a source of pride although they also termed the academic programme as challenging.
Many scholars agree that the nursing profession provides the individual nurse with plenty of scope in future career (Chesser-Smyth 2005, p. 18, Norman 2005, p. 19, Vanhanen & Janhonen 2000, p. 82). The awareness acquired through nursing education also enhances nurses’ self-concept of health and well being (Vanhanen & Janhonen 2000, p. 16). However, on a negative note, (Vanhanen & Janhonen 2000, p. 16) observe that the situations and demands faced by the nursing workforce regularly expose them to various health risks including infectious diseases. Meanwhile, it is clear that the benefits by far outweigh the risks that these professionals face.
Mooney et al (2011, p. 29) states the importance of promoting healthy lifestyle attitude in all health care professionals. Mooney et al (2011, p. 29) and Carlson and Warne (2007, p. 193) agree that there is a strong link between the healthy nurses personnel and better health outcomes within the population. Carlson and Warne (2007, p. 193) understand health promotion as a holistic concept in which nurses are empowered to improve health and wellbeing at self, patient and environment level. The impact of nursing education on nurses’ personal and professional lives has been measured by various studies (Button 2005, p. 319, Altun 2002, p. 271, Rosenstein 2002, p. 31).
In the research paper by Button (2005), focus is on a review of literature how international placements impact on the practice and lives of nurses. Botton’s study was carried out against the background of the need to appreciate that healthcare institutions are becoming progressively aware of the urgent need to respond to the diverse needs of patient populations while at the same time enriching the nursing profession both globally and locally. In this regard, international exchange programs have become a common phenomenon, whereby the objective is to offer nursing students experience from diverse healthcare systems and cultures.
For Altun (2002, p. 274), focus was on a descriptive study aimed at establishing the relationship between the level of burnout among nurses working in Kocaeli, Turkey and their personal as well as professional values. The duration of the study was December 1999 and January 2000, and the sample was obtained from the population of nurses working in two different hospitals within the Kocaeli region. The outcomes indicated that the personal and professional values of nurses play a critical role in determining the level of burnout that they experience.
Benefits of international education and career development
There is much of literature reporting that international nursing placements are of significant impact on nurses’ personal and professional development (Button et al 2005, p. 49, Cohen 2005, p. 93). Moreover, different studies have confirmed that such programs are a source of unique to enhance their critical appraisal skills, wider knowledge use, advanced practice, and research capabilities. This development in international nursing practices, therefore, is a source of plenty of scope for individual nurses in their future careers and improved nursing practices.
Moreover, international education influences cultural competence skills, cultural issues as well as cultural care, each of which is considered a vital element of nursing education (American Association of Colleges of Nursing 2007, p. 7). The commonly held argument is that the understanding of cultural issues and competency constitutes a key part of the profession if the diverse needs of the global population are to be achieved (American Association of Colleges of Nursing 2007, p. 8).
Apart from cultural issue, international placements also contribute to increase in global health awareness, intellectual and personal development in nursing students. This is evident even in the international experience of American nursing students studying abroad. International experiences are also seen to augment cognitive growth with regard to competence in different nursing skills, including reasoning, judgment, health assessment, and evaluation.
Moreover, international nursing education has been seen to be an excellent source of opportunities for students to look at the health care system abroad and then compare the strengths and weakness of their home country. This takes the form of a stimulus for nursing students to return to their home countries and incorporate a multicultural perspective into their practice so as to achieve even better outcomes. Furthermore, these experiences are a source of change in their perspective in terms of personal and professional growth in their career.
International perspective
From an international perspective, nursing education is seen as the backbone of the profession with regard to the provision of competent health services. Internationally, there is a trend in nursing education of moving from hospital-based training to university-based training and with the bare minimum requirement being degree-level training for practising nursing. In some developed countries such as Canada and New Zealand, the minimum-entry level for nursing practice is bachelor’s degree-level education. In the UK and USA, there is a growing trend towards making the degree level of education the minimum educational level for nursing practice (Park 2006, p. 92). In Asia, Thailand has already been maintaining a 4-year nursing education degree program. In Bangladesh, the duration of the course has been expanded to cover four years while in India, a diploma in nursing now takes 3.5 years to complete (Sloand & Bower 2008, p. 37).
The new trends in nursing profession seem to emerge in response to advancement in the health care industry (Lee 2004, p. 119). For most developing and developed countries, this move is aimed at focusing on health promotion and disease prevention. This move is a viable one, considering that across the world, the burden of health services on entire health care systems remains enormous. Health promotion activities are viewed as enablers in efforts to decrease the demand on health and social care services. For this reason, health in turn will increase social capital and economic productivity in a country. In this regard, it should be borne in mind that owing to modern sedentary lifestyle, many chronic diseases are emerging as a great challenge for countries to address collectively (Whitehead, Wang, & Wang 2009, p. 61).
Chapter Three: Methodology
The nature of my research question made it necessary for this study to adopt a qualitative approach as opposed to a quantitative one. This is because the underlying aim was to search for meaning in a rather broad and high subjective sense as well as from a social perspective. This is in sharp contrast with a quantitative study, which ideally seeks to find out the ‘truth’ in an objective, generalisable, measurable, and concise way. Information was obtained through semi-structured interviews within the framework of a phenomenological approach. The underlying aim was to understand the experience of graduate nurses in nursing education within the health promotion perspective.
The meaning of qualitative research was analyzed to ensure that I understood this approach in the same way that some established researchers did. Qualitative research has been defined simply as the ‘development of concepts that help us understand a variety of social phenomena in a natural (as opposed to experimental) setting, giving due meaning to experiences, meanings, and views of participants’ (Pope & Mays 1995, p. 82)
Traditionally, the public health field used to adopt a quantitative paradigm that is similar in various ways to that used in the medical profession. Although this approach is necessary in some areas, such as control and management, it is unnecessary in others, such as the diverse issues of social deprivation, community empowerment, and lifestyle choice. As the role of public health practitioners continues to extend in terms of scope, so does the research problems and the corresponding research methods. This does not in any way mean that qualitative research is either superior or inferior to quantitative research, but that it is simply different. This is why qualitative and quantitative research methods are sometimes considered antithetical. However, because of the differences in their methodologies and aims, a researcher can complement them in the process of generating new knowledge. In this process, the qualitative research generates theories and explores meaning while quantitative research provides a platform for testing these theories in terms of causation and generalisability.
Phenomenological approach
As a research method, the goal of the phenomenological approach is to describe a phenomenon in the form off a ‘lived experience. Since the researcher has to analyze narrative data qualitatively, the methods of data analysis have to be different from the traditional or quantitative research methods. This approach requires the participant to describe his lived experience, which is then gathered and analyzed in the form of a research study. Like in the case of the present study, one can use interviews as a way of gather experiences as described by participants. The participants may either write their experiences or they may be transcribed by the researcher, like in the case of the present study.
Phenomenology is a descriptive process that was developed by Husserl, a German philosopher of the 20th century. The theory behind Husserl descriptions of phenomenology is different from that of other researchers. In this approach, experiences are described from the perspective of the individual. In this way, it becomes easy to ‘bracket’ the assumptions and usual ways of perception that may have been taken for granted for a long time. This is based on the concept of individual knowledge and subjectivity, which highlights the lived significance of individual’s perception and understanding.
Phenomenology describes a particular phenomenon, as lived experiences of several individuals, in the case of this study, ten. Phenomenon is the concept of experience by subjects being studied. The term ‘lived experience’ is defined as an individual experience of people as conscious human beings. Ultimately, phenomenology is aimed at achieving a deeper and broader understanding of phenomena. In retrospect, the main aim of this study to understand the participants’ experience of living in real life as nurses. A phenomenological model was employed because it provides a logical framework that best supports the purpose of this study. The focus of phenomenology in the present study is to understand the essence of experiences about nursing qualification. Specific focus is on nurse’s personal and professional lives as health promoters, improvers of professional practice and community health educators.
The phenomenological approach is employed in this study in such a way as to facilitate a deeper understanding of the experience of graduate nurses in nursing education from health promotion and higher education perspective. This approach provides a logical framework that supports purpose of this study. The researcher endeavours to be as non-directive as possible. As opposed to a questionnaire or a survey, a phenomenological study entails asking participants to describe a specific experience without directing or even suggesting their description in a particular way. All that the researcher is required to do is to encourage participants to fully describe their experiences, including their feelings, thoughts, sensations, images, and memories. In other words, they should express their stream of consciousness, alongside the situations in which the experiences occurred. The researcher may have to ask for a clarification of details on interviews or self-reports. If this is the case, the researcher’s follow-up questions ought to entail asking for further descriptions of detail without any suggestions as to what is being sought.
Phenomenological approaches are powerful tools for use in the interpretation of subjective experiences. Phenomenological research aims fundamentally to depict as opposed to explaining. It ought to begin with perception, which should be free from theory or bias. Phenomenological methods are mainly efficient as tools for conveying from the outset the knowledge and perceptions of an individual from his own insightfulness.
The choice of phenomenology has been chosen over other approaches because of the need to understand the essence of experience about the phenomenon of being an international nursing graduate student from India and UK. In this study, reliance is on the life of an individual and not on the situation where it appears as if the individual has been recruited to talk. In each instance, focus is on ensuring that every single individual gives his own life experiences as accurately and as freely as he can.
In theoretical terms, the grounded theory was considered highly relevant. The grounded theory refers to any theoretical framework derived from an inductive analysis of a corpus of data. If it is done accurately, this means that the theory that one derives fits at least one of the data sets perfectly. This is best understood if one contrasts it with theory that has been derived deductively from other grand theories, without any use of data. Such a theory would result in framework that does not fit in with any data at all. In grounded theory, focus is on a case as opposed to variable perspective. However, the distinction is not always easy to draw. This implies that a researcher has to take various cases to be wholes, whereupon the variables are interacting as a unit so as to bring about certain outcomes. In a case-oriented perspective, such as the one adopted in the present study, the assumption is that the variables are interacting in complex ways.
In grounded theory, focus is also on the comparative orientation of case-orientation. A comparison is made between cases with different variables so as to determine where causes differences lie. Similarly, some cases with a similar outcome also require to be examined so as to determine the conditions that they have in common, thereby enabling the researcher understand all the necessary causes.
In the framework of grounded theory, there is essentially a series of steps that require to be executed carefully so as to ensure that good results are guaranteed. This is just as correct as asserting that one can best evaluate the quality of a theory by determining the process by which this theory has been constructed. This is in contrast with the scientific perspective, which emphasizes that the way in which a theory is generated is irrelevant; what matters in determining the quality of the theory is its continued ability to explain new data.
The grounded theory not only describes the topic on how to develop theory, it also explains the context for the development of adequate theoretical conceptualisations of findings. Although this theory has some common similarities with phenomenology, every aspect of the methodology has to be put into consideration when the researcher is selecting and analysing all variables. The basic idea in the grounded theory is the need to read and re-read a specific textual database, an example of which could be a corpus containing field notes, or in the case of the present study, a narration on the nurses’ experiences. Then, variables, which take the form of concepts, categories, and properties, need to be labelled. The labelling process should extend to the interrelationships between these variables. The researcher needs to maintain theoretical sensitivity by being able to perceive variables as well as the relationships between them accurately. This sensitivity, though, may be affected by different factors, including the researcher’s reading of literature as well as the use of techniques aimed at enhancing sensitivity. The present study has no leaning on any specific theory for use in developing focus on the meaning of what nurses’ experience are with regard to nursing education as well as personal and professional lives.
Ethnography, which is a qualitative approach, was also considered unsuitable because of the nature of the research study. Ethnography examines the patterns of behaviour, customs and ways of life. In literal terms, the meaning of ‘ethnography’ is ‘portrait of a people’. It is essentially a research method in social science that is closely associated with sociology and anthropology although it is not exclusive to these disciplines. Ethnography describes culture from the point of view of the researcher, who has to define perspectives from both the inside and the outside. Sometimes it is known as participant observation, whereby the researcher has to live within a certain setting and among the people he is studying. The scope of the present study made it impossible to go and live among nurses who have attained their education in the UK and in India.
In terms of function, ethnographic research is a source of richly detailed, highly descriptive portraits of groups, cultures, and institutions. Such in-depth becomes the basis for further research, including comparative work. In ethnographic research, reliance is on qualitative methods of producing data, mainly in the form of written descriptions and quotations. The main benefit here is that by living among the people under study and observing the group in the process of carrying out their activities, ethnographic researchers easily bring out the perspectives of both an outsider and an insider. Although it is normally associated with studies of exotic cultures, ethnography can be applied in many other settings, including those on public health, education, and other institutions. The decision not to use ethnography in the present study arises solely because of the limitation of scope, owing to the nature of this research.
The understanding of the different qualitative approaches enabled the researcher settle for the phenomenology approach for the present research study. Among all the above-discussed studies, phenomenology approach emerged as the best-suited perspective for the research topic and the variables under study. It provides a rich and deep description of real human experience and meanings of the phenomena within a scope that the researcher is able to handle within the prevailing research circumstances.
It is important to note that any phenomenology study entails using a preconceived notion. This is where the concept of bracketing comes from. Bracketing is essentially the first step in this type of study, whereby all preconceived ideas and views are put aside so as to understand the experience of the participants under study, in this case nursing graduates. This bracketing strategy, also known as Epoche, every understandings, knowledge, and judgments are set aside and phenomena are revisited naively, freshly, and in a wide-open sense. This is the reason why it was important for the researcher to consider putting aside all pre-conceived thoughts so as to avoid any bias of the study during data collection and analysis.
Data collection
In the present research study, an interview technique was used together to investigate the lived experience of nursing graduates from both UK and India. Data from qualitative interviews, by its very nature, provides in-depth insights of participants’ attitude, thoughts and actions. In contrast, questionnaires provide only a pattern among a large population. Initially, interviews were used in a complementary fashion with focus group discussions for collecting data. The role of the focus group was to allow group interaction as well as providing great insights into the in-depth data. It also allowed the individuals to disclose their experiences and true beliefs as opposed to mere descriptions of how they wished to be perceived.
A focus group is essentially a carefully planned discussion whose aim is to obtain perceptions within a certain clearly defined are of interest in an environment that is non-threatening and permissive. It is a valuable research tool as well as a highly marketable practical skill. In a focus group there is need for a moderator, a note-taker, participants, and a transcriptionist. A moderator should be carefully selected and his roles clearly understood by every participant. His role is mainly that of the wisdom seeker, moderator or roles, enlightened novice, challenge, referee, and expert consultant.
Unfortunately the plan for the focus group was cancelled due to the busy schedule of the graduates and they were unable to meet at the same time as the focus group needed at least 6 – 12 participants. Delays in conducting focus group would lead to a delay in analyses of finding and discussion, which would further lead to delays in the progress of the dissertation. However, this is expected to have little impact, if any, on the consistency of data. This explains why the idea of a semi- structured interview alone was not entirely a bad decision.
Semi- structured interviews
This small-scale qualitative research study was undertaken in efforts to understand and investigate the lived experience of Indian nurses in nursing and professional education from India and UK, which is the main issue of concern in the present study. To completely capture the experience and impact of graduate’s nurses, semi-structured interviews method was employed. The participants were interviewed during the duration of the research. Each interview was lasted for about 40-50 minutes and was recorded by the use of tape recorder to make sure that student perceptions and experience were accurately recorded.
The interview involved open ended and informal questions (see Appendix) so that lived experience of nursing education of phenomenon were accurately understood. The interview was designed in such a way that encouraged participants to explore their perceptions, experiences, and attitude, thereby enabling them discuss many things in great detail.
The use of semi-structured approach is useful for asking broad question relating to the topic under investigation (Polit and Hungler, 1997, p. 49). The Participants were asked to describe their experience. Moreover, to wholly understand the experience probes were given for detail and clarification of the phenomena. The researcher was aware that hinting at the crucial areas of the study through probes could easily lead to the risk, hence the need to take great care.
A total of 10 semi-structured interviews were conducted individually. Some interviews were conducted at the University of the West of England at Glenside Campus while others were taken at the participants’ workplaces. These interviews were conducted in a separate room to avoid disturbance. The interviews were conducted according to the time and place that was more convenient to the participants. Additionally, the place chosen was such that the participants could feel relaxed and comfortable throughout the duration of the interviews.
A pilot test was also carried out before commencing the research study. The aim of the pilot test was to ensure that the data obtained had the viability of achieving the aim of the research study. The test was also aimed at confirming the ability by the researcher to obtain accurate data. The data collection process was continued until saturation occurred. The nursing graduates were encouraged to talk freely about the topic introduced through different questions. During the interview both the researcher and participants were actively engaged in constructing a version of their world.
Recruitment and sampling
Presently, there are total of 4 cohorts of Indian international nursing students in UWE, Bristol. One of the cohorts has just started their course while the other is almost finishing. The other two cohorts have already achieved Professional Studies Degree in Nursing at the University of the West of England, Bristol. Therefore, the sample will be recruited from those cohorts of students who have completed their course of study since all groups are from the same background. The recruitment was made from the first 3 cohorts who have completed their studies at the University of the West of England, Bristol.
Sampling theory was used to determine the most effective way of acquiring a sample that would reflect the population under study. Therefore, the purposive or judgmental sampling technique was used for recruiting the participants. The participants involved in the study were sampled using non-random methods. The aim of this technique was to select the sample with particular characteristics because they possessed knowledge that was valuable to the research process. Initially the plan was to recruit the sample size of 8 to 10 Indian nursing graduate students who shared the common characteristics. But at the end of the day the researcher succeeded in recruiting 10 participants, which was the maximum limit for the research study.
Recruitment of the students was initiated by obtaining data from university records with the help of the programme leader of nursing graduates. Email system via internet was used to send the recruitment advertisement and request the graduate nurses to be a part of the study. The recruitment advertisement included the purpose of the study, the inclusion criteria and basic information relating to the study. Contact information was also sent to the graduates (see Appendix 4). In the first week, I got three volunteers but one was disqualified because he was still in his course for the re-sit exam. But in the following weeks I received a very good response from the graduate nurses that helped me to increases my enthusiasm. In good time, the 10 participants were recruited.
For the interviews, the graduates were first assessed for their willingness and some spare time was allocated for a discussion of the research study with the participants. Personal contact was also made only when they were eligible according to the inclusion criteria. The detail of the study was briefly explained verbally and information sheet was given to keep. Their written consent was obtained according to the willingness of the participants. The copy of information sheet and consent form was attached as shown in Appendix 2.
Data Analysis
Data analysis commonly begins while the interview process is going on or during field work so as to make it easy to organize and give meaning to the data. Throughout the study, the qualitative data analysis and management was conducted sequentially in an ongoing manner. It was also considered that in order to analyse the qualitative data it is important to use a system that is consistent across the whole data set. To manage the large body of information during data analysis stage and to make flow of data easy, I used a practical manual approach.
The data were transcribed into text where the transcript-based analysis was done to identify the emerging themes and statements collected into specific categories. The themes were developed into categories of data, whereby transcripts had to be read and re-read and field notes carefully studied. As the process of going through the new categories was identified, the transcripts were re-checked every now and then so as to retain all the relevant information. Issues that recurred between subjects of particular interest were identified for similarities, linkages and differences in themes owing to their great potential for generalisability. Quotations from transcript were used to point out the themes and sub themes and also written while building up the final findings report. Any peculiar information such as names of the participants was replaced with pseudonyms. These names were retained throughout the remaining research process to ensure compliance to confidentiality requirements.
Verification Techniques
Verification techniques were put into consideration so as to determine to what extent the research study was trustworthy and rigorous. The verification is a process ought to occur throughout the tasks of collecting data, analyzing it, and writing the final report (Creswell, 1998, p. 193). The aim of verification is to achieve systematic understanding and interpretation that is recognisable and understandable to research subjects and one that is achieved on its own terms. According to Guba and Lincoln (1980, p. 40), reliability and validity entail the parallel concept of trustworthiness, which contains four aspects: credibility, transferability, dependability and conformability. Normally, one cannot rule out the chance of threats to the reliability and validity of an investigation mainly in the form or bias or error in the course of the research. The verification process enabled the researcher to remain vigilant for any instance of biases and errors.
Purposive sampling was used for recruiting the participants for data collection. However, the problem of generalisability of the results to the entire problem could not be wished away. This is largely because of the small size of sample, the limited cohorts of students, and limitations arising from the research site. Credibility was achieved by cross-checking the themes by my friend to ensure that the findings made sense with regard to the confines established in the research question. Triangulation method was also be used to further clarify on the credibility of the findings. In terms of dependability the findings could very well be relied upon by the population. Towards this end, equivalence checks were conducted within interviews by asking similar questions and evaluating consistency of the informants’ answers.
Ethical and Governance issues
The University of the West of England, Bristol was selected as the research site from where graduate nurses having the diploma from India and a one year top up degree from UK were approached. In order to commence any research study, the researcher must obtain permission from the setting or agency ethics committee where the study is to be conducted (Polit and Hungler, 1997, p. 93). The university ethics sub-committee has been working in line with these requirements for the last few years. The consideration of research proposal by ethics subcommittee ensures that potential participants are protected from any potential harm. According to Denscombe (2002, p. 102), researchers have a duty to work in a way that minimises the prospect of their research having an adverse effect on any people who are involved. In considering this statement a dilemma relating to the differential power dynamic between the research participants and the academic researchers have to initially be resolved. Within this study, therefore, the first consideration prior to seeking ethical approval was to ensure that all information about the study was available in a fully accessible format.
The project has been reviewed by the University Research Ethics Committee (UREC) and Faculty Research Ethics Sub Committee (FRESCs), School of Health and Social Care from the University of the West of England (UWE), Bristol. And the approval was given in January 2011 with little change required by the committee. The Final chair approval was given in February 2011 to proceed with the project. The project includes the participants (overseas nursing students) from the University only therefore there was no need to get the approval from any other sector such as National Health Services (NHS).
There are various different ethical issues that I considered during the interview period. For one, interviewing the overseas graduate nurses about their professional and personal experience might be disturbing, frustrating, and upsetting to them. Most of them are living away from their countries and families. Moreover, the comparison in practice in India and UK has the potential to trigger ethical concerns because of differences in nursing policies and practices. It was also put into consideration that the size of the study was rather too small for such a wide-reaching topic of study. Although, these issues were not highlighted in the research question, it was not lost on the researcher that participants might want to talk about them in the process of clarifying their answers.
In terms of consent, security of information, and confidentiality, this study entailed approaching UWE students who are living in a foreign country so that they could talk about their far-reaching experiences. For this reason, the researcher did not think that the discussions held during interview sessions might be emotionally disturbing for them. If the participant felt distress and emotionally disturb, the interviewer simply ended the interview at that point. Moreover, the programme leader and student advisor or a counsellor from the university was always at hand to support the participants if necessary.
The detail of the research study and what was expected from them was verbally explained along with one copy of the information sheet (see appendix 2) before obtaining the written consent (see appendix 2). Moreover, their right to withdraw from study at any time without giving any reason was clearly explained, together with the right not to answer the question. The two copies of the written consent form were given to the participants and I kept one signed copy of the consent form for my records.
The researcher confirmed to both the participating students and the ethics committee that the information provided by the participants would be treated with ultimate confidentiality. Indeed, throughout the research process, confidentiality was a crucial part of the research process. The study material and information provided by the participants are stored in computer protected with a password and only the researcher and researcher supervisor can have access to the material. Moreover, the names used in the interview transcripts were anonyms; the respondents’ names were only contained in the consent forms. Upon signing, these consent forms were safely kept under lock and key. The names of the participants were not enclosed in the research findings either. When transcribing the interviews, all the names of the participants were immediately replaced with pseudonyms.
Chapter 4: Results
The results of this phenomenology study provided the in-depth understanding of the lived experience of Indian international students of nursing education from India and UK on their personal and professional lives. Ten Indian graduate nurses were interviewed and asked to describe their experience of nursing diploma and degree. Each interview was conducted and transcribed as described in the methodology section. Transcripts were analyzed by using the phenomenological method. The units of meaning are listed and clustered into common themes used to develop a textural description of the experience. This integration constructs the essence of phenomena.
Every participant expressed a unique experience of nursing education on his or her personal and professional life. However, some similarities emerged from the various semi-structured interviews, which were discerned after an analysis of interrelationships with regard to the way different participants responded to the same questions. The main interrelated themes that emerged include role as a health promoter, health awareness at both personal and family level, the need for higher education, influence of professional studies, benefits accruing from professional nursing education, career opportunities for the future, and workplace challenges.
On the first theme, that of health promotion, the participants said that the nursing education had provided them with an in-depth understanding health and individual well-being upon completing their nursing degree. This affected both their personal lives and their family lives, including the way in which they perceived health awareness. Harry, one of the interviewees, said that he had learnt a lot of things upon completing his nursing education. He said “I now help myself regarding health promotion and I can give advice to others and to my family as well as to the people surrounding me”. Harry added “I now know more about nutrition, how to protect myself from communicable diseases, to maintain a healthy environment, and basically to deal with problems regarding health”.
On her part, Navjit said that nursing has changes her life a lot. She said: “before doing nursing, I was not aware about many health illnesses but after completing education, I came to know about the human body, the physiology of diseases, treatment, prevention, and many other things”. Navjit also explained how the nursing degree had transformed his personal life as well as her family. For instance, when her grandmother had stroke “I knew how to rehabilitate her and I was the one performing the role of a ‘carer’ in addition to doing so many other medical procedures”.
Daljit said “I have a very good experience and I learnt about health and wellbeing. After completing my study, I can cure myself and others from diseases. Before I gained the training, I just had a general knowledge about health and how I could promote health. Now I have learnt both theory and practical experience of management of diseases”. Yohesh echoed similar sentiments although she went on to specify that she know knew all about the side effects of excessive drinking and smoking. She added: “you know before I used to drink in one day you know but now I come to know this very bad and I tell to my friends and relatives for that and ……is very beneficial to them”.
Jatinder said that “basically, from my experience, the nursing course has been a great experience because you can now know how to prevent yourself, promote your health, and prevent your family as well as the community” Jatinder also mentioned that without nursing, he would not have been aware of many medical issues such as how the body works, how to undertake prevention measures, and everything there is to know with regard to a nursing degree.
Harsimran also said that he “had a good experience after doing his nursing degree”. He observed that before undertaking the nursing course, he was not aware of diseases and their causes, but upon completing the studies, he was “much more aware about the incubation period of diseases as well as how the cycle of diseases works”. For this reason, Harsimran sees himself as well poised to become a health promoter. Regarding attitude, Harsimran said that his attitude had changed tremendously because “when I go somewhere and see something unhygienic, I am definitely going to talk about it with the concerned person or family member”. On this same issue of attitude change, Jatinder said that without nursing and medical knowledge, one cannot promote his or her health. She noted that “if you understand how your body is working, then you can know when something is going wrong with your body”.
The second recurring theme was on the role of a nursing professional as a health educator, and the way this role remains helpful in promoting health and preventing disease. This theme emerged after the researcher asked the interviewees to give an example of an experience as health educator within the community. Specifically, the prompt was on the people’s reaction, whether they acted as good followers, and how the interviewee encouraged them.
Harsimran recalled that as a nursing student, he used to visit community health centres in rural areas where “we used to give health talks on different topics like…umm… smoking, mainly because many people do not know that smoking affects the lungs”. Harsimran further indicated that “sometimes people would ignore us, but I cannot recall the strategies we were using to encourage them. As for some families, we used to give general nursing-related tips as a way of encouraging them to adhere to hygiene, particularly on the issue of sanitation”.
Jatinder also recalls attending a community health awareness session to give a health talk. Jatinder remembers one health awareness session, where a lady came forward and complained of suffering from a strange respiratory disease. We realized that his husband was a smoker and the lady had gotten the lung disease through passive smoking. We educated the public regarding the dangers of smoking on the health of everyone and how to deal with this type of addiction.” For Yohesh, the narrative is almost similar, whereby participation in community health education programs was a highly enlightening experience as much as she can remember.
Harry was frank with his personal experience, where, as a student nurse trainee, “we would discuss with people about how to manage their problems; sometimes we used to ask them about their experiences with the immunization program.” He added: “we found out that some of the people were not aware the importance of immunization because when I ask them when their kids are going to have a polio vaccination, they say that they are not aware”. “Owing to their lack of knowledge, I convinced them to make sure that they follow up on vaccination so as to prevent their kids from contracting the dangerous diseases such as the polio virus,” Harry said.
Najvit’s experiences transpired during her stint as a nurse with a posting to a rural area in India. “In that community, we used to contact with so many peoples (sic) and the main illnesses included tuberculosis, HIV/AIDS; some people did not know that they were suffering from those diseases”. Daljit also says he had a good experience, whereby he used to go to community health education sessions and meet with people from all walks of life. For example, says Daljit, “there was one lady, I saw her, she was very fat, like she was obese, and had difficulty breathing. She was restless because she could not breathe well. I talked with her about her diet, I asked what type of diet she usually eat, and she told me she take too much salt and eat fried things. I teach her that she must reduce her salt and she must eat boiled foods more than oil foods and fatty things. She should also go for regular check-ups and perform many exercises. When I met her after one month, she was very good and she told me she is doing her exercises and she is feeling very happy because she can do her work without any breathlessness”.
The third theme was on the influence of professional education. The interviewees talked about how their thinking changed, how they are now looking at things differently, their attitudes towards health promotion, and evidence-based practice. Harsimran said that “nursing education has had a very good impact on my professional practice because now I have become a critical thinker. I can think more critically and now I can analyze many things than before. Previously, I was more into practical work and I did not know any theory”.
On her part, Jatinder jovially agreed that she had learnt a lot when she was in India for a diploma course in nursing. However, she describes the contrast between experiences in India and in the UK. She added: “In India, we were following the same routine like everybody else, but here you are independent, you can make your own decision. So when I did my degree here, it tells me how to reflect on our bad things and how to improve your further practice. For example, I did a research on dementia and I have learnt a lot on how to help people suffering from dementia”.
Similarly, Yonesh’s views were positive on the influence of professional education. This is how Yonesh put it: “the impact of the professional education I did here was very beneficial. When I was doing a diploma course, I did not have any critical thinking knowledge. I never thought about how to analyze some of these things; I did not think that these things were an important part of education either”. “Thanks to the professional training, I am now able to focus on prevention aspects of nursing as well as things relating to attitude. I know that I always need to focus on promoting prevention first in order to succeed in getting the desired health outcomes.
Harry emphasized the role played by both cross-cultural study settings and practice-based issues that he was not previously aware of. He said “I have improved a lot while I learnt from a cross-cultural environment, so now after doing my education, I learnt about practice-based issues and how to reflect on previous practice; so it is quite a lot”.
For Navjit, the observation made is that UK curriculum and professional leaning is mostly evidence-based. She says: “Like everything in the UK, everything we have read is evidence-based; every nurse must produce evidence before implementing anything and looks at everything differently in every area. We have to think like extraordinary thinkers, critically; so we cannot just follow the way and go ahead and have to think critically about how it will affect our next step”. Navjit added: ‘here in the UK, everybody got a high range of knowledge. Reflective practice here in the UK is a very important part of nursing. If we have done something wrong in our previous life, we have to reflect on that incidence so we can improve on our next step and prevent a disease from occurring since prevention is better than cure”.
Like Navjit, Daljit talked about the impact of professional nursing education on his thinking level. He said that after doing the study, he nowadays thinks more critically than ever before. “I think about many things before I do anything; before, I was rushing into action too quickly, but now, I think more critically. I think I have done 2-3 modules in my study, and this gave me different knowledge. I have learnt how to think deeply about diseases and how I can prevent them, how I can prevent the community from diseases, and how I can handle them properly. If the people do not understand one way, I have to try another way; now I can teach them better way”, Navjit said.
On the fourth theme, which covered the benefits of foreign study, participants were expected to talk about how the cross-cultural learning experience affected their personal lives and professional development. Lada noted that his life has been changed because of the fact that he has learnt about health promotion, preventative approaches, and the need for objectivity in a new socio-cultural environment. For Baljinder, the highlight of his views was socio-cultural sensitivity. Baljinder said that he realized that we are all one people as far as health needs are concerned; some health challenges are shared the world over. Marcy, on the other hand, kept emphasizing the need for efficiency. She reiterated that efficiency is necessary in ensuring success in efforts towards better health care. When efficiency is achieved in cross-cultural contexts, the resulting positive outcomes become very fulfilling. Other exciting areas of focus for Marcy included critical thinking, leadership, communication, and cross-cultural consciousness.
Harsimran said: “in my professional development, while doing and after doing that course, I can say my leadership skills are better; I also learnt about leadership skills”. Jatinder’s views go deep into specifics, whereby she refers to dementia once again. She says: “basically, the benefits (of foreign study) are all covered in my education; but the thing is I did my degree in dementia because we were not aware of why age is a major factor in this disease; now I know”.
Yohesh said: “before taking this course, I was not able to communicate properly regarding what I want communicate, or if I wanted to give a talk on health education. Regarding safe sex practices, I was not able to do that because of my culture…or… I could say… you know… I was not happy to give a talk on sex education. When I came to this country, all this changed because I realized that it is possible for people to talk about sex education freely without shying off”.
On his part, Harry is grateful for the cross-cultural experience since it enabled him to learn a lot about communication. “Nowadays, I am able to reflect a lot on in-depth studies that I have done, especially on pressure sore and nutrition. Specifically, I understand the impact of nutrition on pressure sore, how to improve the condition of the patient. I did an independent study and research on it quite a lot and found that if we improve nutrition and diet, the pressure sore can be improved, and…. you know… it can cure as well”.
In Navjit’s view, foreign studies have changed his entire personality. “My profession and personality has changed because in India, we do not openly discuss about sexual needs. Since I came here, I came to know that sexual expression is a normal way and people do take it normally,” he says. Navjit also feels that his communication skills were improved, considering that he can say so many things to people in a normal way without the people considering it coercive, rude, or as an abuse. “So I got this knowledge as well; how to communicate with others in a normal way”.
Daljit said: “I think my professional development is like my communication: I developed and learnt more about leadership during the foreign studies. I can now learn now very deeply about how to solve problems at the initial stage. I have also learnt that whenever there is a problem, the best thing is to solve it at the initial stages. When we were in India, I was in a country where culture is different, and we never used to talk about sex. I could not give a talk on family planning methods. I could not talk openly about family planning. After this training, I can discuss this more openly and I can communicate this thing. You know is a very populous country and I can control the population while giving them good advice about family planning methods”.
On the theme of future expectations, the interviewees reflected on their future roles, particularly how their future roles had been affected upon acquiring nursing education. For Jatinder, the nursing training “is an opportunity for her to work with dementia people like in a big hospital”. “With this degree, I can prove to them that I am aware of dementia, so I can work in the dementia field like a professional”, she added. Lada maintained that the nursing education would enable him educate the members of his community about ways of preventing themselves from contracting diseases. Bajinder, on his part, expressed interest in furthering his career, a crucial step of which is enrolling for a masters’ degree in nursing in a reputable UK medical institution. Marcy was of the view that working with the community is a great source of satisfaction as well as well as opportunities for career progression. Harsimran said that he expects to be in general practice in the future, where he will have some autonomy while at the same time getting an opportunity to work with all members of community in improving health outcomes.
For Yohesh, the ambitions are in the realm of managerial work, whereby she hopes to get an opportunity to be the manager of a nursing school. “I could even be the manager of a nursing home,” she insisted confidently. “I could also teach…. you know… like I could be a nursing tutor and I could be like a supervisor in any good hospital because I have gained all those skills that are needed for a manager with a diploma; I mean this degree has helped me to become a manager some time. I think I have all the skills that a manager should have and I would definitely be a manager somewhere”.
For Harry, the future opportunities lie in either mental health nursing or midwifery. He is also confident about getting an opportunity to work in childcare in the future. He says: “I can work as a community health nurse and a public health nurse. That course can take me anywhere; I got the basic knowledge that can take me where I want to be”. On his part, Navjit was more specific on the opportunities that he is looking for, thus: “I want to become a registered nurse in the UK”. Daljit was similarly clear on his future plans: “I plan to teach students when I go back to India”.
Meanwhile, as one would expect of a phenomenological study, there was a tendency among interviewees to give feedbacks that they thought the interviewer expected. In other words, there was a tendency among the individuals to refrain from giving answers that indicated a deviance from the norm. For instance, no one expressed fears regarding the future of their nursing careers, yet in ordinary cases, it is difficult to find someone who has never exhibited such fears. The researcher noted that the interviewees tended to ‘clothe’ such fears in elaborate accounts of certain significant events in their lives and the way they responded to the challenges of the day. For example, one interviewee went into great detail to explain how her grandmother struggled with dementia and how this influenced her to want to learn more about the disease, specifically the old-age factor.
Chapter 5: Discussion
Owing to the size and restrictions of this project, data saturation was not likely to be accomplished. Nevertheless, the grounded theory approach has still enabled the researcher to identify numerous valuable points. Many issues pointed out in this research are of great significance and deserve further discussion. Key among these issues is the impact of nursing education and health promotion in the UK and India. These issues are of great relevance in efforts to improve the state of public health the world over. This project being a master’s dissertation in public health, it is crucial that further highly relevant issues in public health promotion in nursing be pointed out. This is the main reason why a lot of emphasis was put on what the interviewees had to say regarding health promotion in the community and in health facilities and the way this impact upon their personal and professional development. It is also for this same reason that I shall focus here on a small number of themes relating directly to the aims of this research paper, namely, experience and perception of nursing education among nurses, the impact of studying in foreign environments (India and the UK) on the development of professional nursing practice and health-promoting skills, how this education contributes to the individual’s health and improved practice, and how this training enhances the personal development and skills of nurses.
Experience and perception of nursing education among nurses
Most of the interviewees were upbeat and optimistic regarding the training that they had received in medical school. The positive perception was clear in the fact that each of them had a clearly visualized career objective and future opportunities that they perceived to be within reach. As one would expect, the perceptions of these interviews were shaped partly by their own life experiences outside school and partly by the health promotion, thinking, and professional skills they had acquired at medical school. The main areas of positive perception include health promotion, health awareness at both the personal and family level, the need for higher education, the positive influence of professional studies, opportunities for the future, workplace challenges, and community-oriented benefits accruing from professional nursing education.
The general feeling among participants is that their first degree is a source of empowerment with regard to their understanding of both individual well-being and health in the community. At a personal level, the impression created is one where nurses regard themselves as leaders and role models in community health promotion as well as sources of advice on preventive measures both within the family and in the immediate neighbourhoods. The nurses appear to have taken it upon themselves to inform the community about proper diet, prevention of communicable diseases, and basically dealing with problems regarding health.
A rather interesting finding was that the interviewees did not seem preoccupied with getting many followers in the community. This is clear if one considers that it only two out of ten interviewees who expressed interest in entering into private practice or seeking managerial positions in local health facilities or nursing homes. The assumption here is that such over-ambitious goals indicate an equally over-expressed sense of self-worth. This sense of self-worth is normally an indicator of an individual’s willingness to be preoccupied with the task of seeking followers within the community.
The impact of studying in foreign environments
All the interviewees also endorsed the universal role of nursing professionals as health educators. The interviewees perceived this role to be helpful in efforts to promote health and prevent disease even in foreign environments. The only area where interviewees expressed discomfort was with regard to culturally sensitive issues such as sex education. The nurses who experienced discomfort were those working in cross-cultural settings. However, upon getting used to their new working environment, they tended to become used to the host country’s culture. In effect, they ended up getting used to talking about sex education without feeling embarrassed.
It is not appropriate to categorize those who point out sex education to be a taboo topic in their cultural settings since it is widely known for a fact that in some cultures, sex is a taboo subject. The same case applies in the case of foreign study contexts, where interviewees acknowledged that they had benefitted from the education that they had acquired. Regarding the benefits of education in a foreign setting, all interviewees were keen to draw a contrast between their perceptions prior to the start of the training and upon completing the nursing training. Generally, the cross cultural training offered them with leadership qualities, communication abilities educator-related skills, critical thinking, and problem-solving abilities.
Contribution of education in improvement of interviewees’ practice
Here, the improvement of practice relates to both health promotion and health education. The interviewees were expected to have answered with this perspective in mind, considering that the necessary prompts were provided. In the study’s results, the indication is that theory is of great relevance to practice. Professional education that contains many aspects of theory enables the nurses to be firmly grounded in their profession. It enables the nurses to change their thinking and to view matters regarding health in a completely different way. It is quite interesting that none of the respondents complained about too much theoretical work at the expense of practical work.
Apart from critical thinking, communication and leadership qualities are cited as crucial benefits that nurses acquire in nursing institutions. These qualities have the power to transform their practice as well as their approach to health promotion in the community. As described in literature, theoretical aspects of nursing provide nurses who have a wealth of experience with an opportunity to find entry into a degree course, which enhances their chances of accessing better employment opportunities. Such nurses could be highly experienced while still remaining sidelined for lack of formal training, something that tends to be a major obstacle in their career progression.
It is also plausible for one to expect the training that nurses acquire to shape their perceptions regarding future career expectations. In spite of slight differences in nursing education in India and in the UK, there are stark similarities regarding the expectations of graduate nurses. For instance, in both countries, nurses come out of college as independent thinkers. This ability to think independently may be used to explain why many nurses expressed the desire to pursue post-graduate studies in nursing. It is clear that they understand the importance of further studies in accessing better career opportunities. Some respondents were keen to elaborate the ways in which they have been applying their newly-acquired skills to help improve health outcomes, promote health, and engage in health education within the community.
As the researcher expected, those interviewees who were operating in cross-cultural settings had a difficult time at first getting accustomed to new cultural values, especially during health promotion, health education, and other related efforts. For half of the interviewees, the benefits of cross-cultural setting in terms of exposure by far outweigh the difficulties. These benefits mostly take the form of awareness on new practice-based issues that a nurse may not have been previously aware of. Upon reflecting on previous practice, a nurse is able to acquire new knowledge that further strengthens one’s professional grounding. It should be borne in mind that in the contemporary world, nursing is one of the fields where labour mobility at the international level is at the highest level. In such a situation, it would prudent to encourage a nurse to gain some cross-cultural experience at a certain point during his practice as a way of increasing his competence and awareness at the international level.
As indicated in Button’s (2005) detailed review of literature on nursing in cross cultural contexts, the most significant changes arising from cross-cultural exposure affect perspectives on nursing, the nurses’ critical appraisal of different healthcare systems, as well as personal and professional development. Each of these areas is closely related to nursing practice, particularly issues on health promotion and education. However, none of the respondents talked about the variations of nursing experiences in terms of duration of programs, debriefing, and placement. Meanwhile, it could be deduced that these issues failed to arise during the interviews because the interviewees presupposed that they were foundational issues that did not require to be emphasized.
Nursing training: a way of enhancing nurses’ personal development and skills
The results of this phenomenology study with regard to training nurses indicate that there is widespread awareness on the need for one to gain personal development skills. The impression created here is that a nurse cannot be an agent of health promotion in the community if he or she is not properly equipped with the appropriate skills at the personal level. Indeed, for a nurse to have positive future expectations, she first has to have a sense of satisfaction at the personal level. Such personal satisfaction is the one that greatly inspires the nurse to seek professional skills, competences, and knowledge.
For those nurses whose personal development aspirations are in the realm of managerial work and private practice, this may be seen to be an indication of a positive self-concept and high self-esteem. The positive perception of the profession also manifests itself in the high level of creativity in terms of the ways in which the nurses wish to utilize their knowledge in the future in efforts to promote health and educate the community. For instance, it is only after gaining a sense of personal satisfaction that a nurse can think about using his nursing skills to engage in tutoring and public talks on sex education.
Getting personal satisfaction within cross-cultural settings may be a tall order, considering that one has to first get acquainted to socio-cultural values practiced in the host country. The views expressed by Harry, for instance, regarding the power of cross-cultural settings in bringing to the surface practice-based issues that one was previously unaware of, are an indication of nurses’ desire to get a lot of educational and professional exposure. Nurses, it seems, expect to get this exposure by acquiring education, training, and professional experience in cross-cultural contexts. Indeed, these views were echoed by all the other participants, with slight variations extending only as far as issues of personal interest are concerned. Such variations are to be expected, considering that in a phenomenological study of this nature, no efforts were made, and rightly so, to confine the responses of interviewees within certain theoretical tenets. They gave out their views as freely as possible, and the farthest the researcher went in influencing the responses was issuance of occasional prompts.
In summary:
- What did we already know before the present study?
The findings of this study support previous evidence that the concepts of health promotion and health education tend to have a far-reaching implication on nurse education. Researchers have in the past identified the need for the development of education strategies and curricular that clearly articulates the ideological formulations of nursing policy and practice. The need for strategies of formulating and facilitating the use of mainstream terminology for assisting nurses to understand as well as contribute to the ongoing health promotion has also been identified. It is also known that majority of nurses appreciate their positions as role models in health promotion, although they seem to consider this to be somewhat a mere perception that differs with their own view of the profession.
It is also known that although there is widespread international mobility of nursing labour, different countries use different strategies of preparing nurses for the roles of health promoters. This situation has triggered some sentiments to the effect that there is need for an international approach to nursing training where health promotion has a broad application. In the meantime, nurses have to keep adjusting to cross-cultural differences whenever they go to practice in new socio-cultural settings.
- What additions have the findings of present study added to the existing body of knowledge?
In this study, an overwhelmingly high percentage of interviewees have indicated the need to promote health and educate communities regarding health promotion and preventative health. There is also an affirmation on the need for nurses to seek higher education, to adapt to cross-cultural challenges, and understand their roles as health promoters. As health promoters, nurses expect to be critical thinkers, to exhibit health awareness at both personal and family level, and to bee constant seekers of sustained personal and professional development in their nursing practice.
- What do we still need to find out?
Researchers still have an uphill task of determining what it means for nurses to derive maximum personal and professional development so as to succeed in their roles as health promoters. Can maximum improvement in nurses’ personal and professional development automatically translate in better outcomes in terms of health promotion and education? This is a question for which an answer should be sought through further research.
Chapter 6: Recommendations
- There is a need for policy measures to be put in place for establishing a standard system of nursing training and practice so that cross-cultural challenges are avoided. This would also enhance greater mobility of nurses internationally, the net effect of which is improvement in health promotion efforts.
- The higher learning institutions that offer bachelor’s degrees in nursing should take their efforts a notch higher and introduce master’s- and PhD-level degrees so as to meet the demand for these qualifications among nurses. It is clear that many graduate nurses of today would be more than willing to pursue a greater academic challenge in efforts to create opportunities and establish firm grounds for personal and professional development.
- Policy measures also need to be put in place to encourage nurses to become better leaders and communicators in their work as health promoters in the community. Although the nurses may admit it, they seem to be covertly expressing a feeling of being overwhelmed by being expected to be role models in health promotion, especially within cross-cultural contexts. On this same note, it appears that nurses would be better off with policy guidelines that have been concisely defined in order to eliminate any possible ambiguities on what is expected of them as they contribute to public health.
- Universities should introduce exchange programs whereby nursing students are given an opportunity to study in foreign environments. This is an excellent way of opening up their perspectives by making them aware of variations in cultural practices and the way this influences nursing practice. Nurses with such exposure get greater opportunities of becoming critical thinkers as well as excelling more in personal and professional development, mainly through improved health outcomes.
Chapter 7: Conclusions
This study was carried out on a target group that was rather difficult to reach. Although the number of interviewees was small, the outcomes are highly significant and they provide a fairly accurate picture of what nurses who gained nursing experience in India and the UK think about their personal and professional development, health promotion, and their positions as role models in improving health outcomes. This was a small-scale study in line with the well-known limitations that come with a master’s degree in public health. For this reason, it may be very beneficial to carry out a larger-scale study so as to ascertain whether or not the various issues raised can be generalized to graduate nurses at the international level.
The results of this study demonstrate that there are still many challenges that nurses face in their personal and professional development. However, despite these challenges, they continue to regard their profession highly. These findings reflect the need to maintain a balance between efforts aimed at improving health outcomes on the one hand and those aimed at the nurses’ personal and professional development.
Graduate nursing students were found to perceive their nursing education experiences in the UK and India positively with regard to both health promotion and personal and professional development. Indeed, this type of training was viewed as a source of cross-cultural exposure and a trigger on the process of nurses’ transformation into critical thinkers. The nurses indicated that they had noticed an increased sense of self-awareness in terms of health, personal conception, career aspirations, and professional development since undertaking nursing training in the UK and Indian contexts.
Although this was a challenging study for me to undertake, the ten nurses I interviewed provided me with very rich and extremely valuable data. This data appears to have largely supported previous findings, made significant contributions to new knowledge, and prompted me to ask some further questions. The next stage undoubtedly entails disseminating these findings and responding to recommendations appropriately. Ideally, such a response should be a way of ensuring that the contributions of nurses never go unheard in efforts to improve health outcomes in the community, enhance preventative health, and ensure the nurses’ personal and professional development.
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