A Qualitative Study on Nurse Educators' Perceptions Regarding Challenges and Strategies of Nursing Education and Practice in Guyana and India
Tabitha Mallampati
School of Nursing, College of Medical Sciences, University of Guyana, Georgetown, Guyana.
*Corresponding Author E-mail: tabitha.mallampati@uog.edu.gy
ABSTRACT:
This study aimed to explore the perspectives of nurse educators regarding the challenges and strategies of nursing education and practice in Guyana and India. The study was a qualitative design that used a convenient and purposive sample of 15 Nurse educators (eight participants from Guyana and seven from India). Ethical permission was obtained to conduct this study from the appropriate IRBs in Guyana and India. The subjects were given prior information regarding the study's purpose, objectives and methodology. Each interview lasted between 30 and 45 minutes and was audiotaped. Audiotapes were subsequently transcribed verbatim. Interview data were analyzed using the R Computer Qualitative Data Analysis (RQDA) software program. The grounded theory and inductive thematic analysis was used. The study's findings supported the literature that nurses were working in a low resource environment. The challenges of nursing education included lack of adequate and qualified faculty, inadequate teaching and learning resources, lack of conducive environment for learning, and inadequate curricular reviews. Additionally, lack of professional image, scope, autonomy and advocacy, poor salaries, limited opportunities for leadership roles at the policymaking level, inadequate clinical experiences, need for in-service education and maintaining professional standards were indicated as challenges of nursing practice. Addressing the shortage of human and material resources and upholding professional values and standards are the critical strategies. The data supported that the government policies, regulatory frameworks, and funding models that foster collaboration was pivotal in addressing nursing education and practice demands. The findings reiterated that quality education is one of the critical prerequisites for generating a quality nursing workforce.
KEYWORDS: Nursing Education, Nursing Practice, Trends, Challenges, Strategies.
INTRODUCTION:
Nursing is a dynamic and practical discipline. Professional nurses must be abreast with scientific knowledge and fluid about the changes occurring in the nursing profession. Research has shown that applying scientific knowledge in nursing practice situations call for skillfulness, sensitivity and creativity. In addition, several global trends are affecting the delivery of quality patient care in the 21st century. These factors included globalization, technology explosion, changing economy, advancements in health care services, shortage of nurses, growing population of the elderly and increased burden of chronic diseases1.
Nurses spend long hours in providing patient care than any other health care professionals2. They are critical in leading influential roles in fast-changing health care settings as clinical practitioners, nurse managers and nurse educators3. Studies report that several measures were recommended to address the challenges of nursing in the 21st century. For example, a study by the Institute of Medicine in the USA in 2015 recommended measures as increasing the proportion of nurses with a baccalaureate degree to 80 percent, doubling the number of nurses with doctorates and fostering lifelong learning2. Other strategies proposed in the literature included advanced practice nursing, nurse residency programs, simulations, distance education and interprofessional education4. However, understaffing is a significant and growing concern worldwide. Specifically, developing countries like Guyana and India continue to lose nurses to rich countries and suffer from severe nursing shortages5,6.
Guyana is the only English-speaking country in South America and has a population of 746,955. The country is bordered by Suriname, Brazil, and Venezuela and has ten administrative regions. The population receives health care at five levels. These include the National Referral Hospital in Georgetown, four regional hospitals, and 19 district hospitals covering 10,000 or more7. Literature supports that many Guyanese nurses migrate to the US, UK, and Australia every year. A report disclosed that Guyana lost nurses at 81.1% and was among the top five countries with the highest rates of nurse migration in the Caribbean region. In addition, the number of English Speaking (ES) CARICOM-trained nurses working abroad was roughly three times larger than the number working in the ES CARICOM8,9.
A study on Nurse Migration in Guyana (2011) by the PAHO highlighted the push factors for nurse's migration in Guyana. These factors were workload and job-related stress, lack of equipment and supplies, inadequate physical facilities, disliked conditions of service and lack of value for the nursing profession. Another significant challenge is Guyanese nurses are not prepared for the Caribbean regional examination for nurses registration (RENR), a qualifying exam for nursing practice at the regional level10. In 2014, a huge failure rate was recorded in the nursing training programs in Guyana due to large classrooms, inadequate nursing faculty, and quality training11.
Likewise, in India, in recent years, the nursing shortage has been significantly on the rise. Reports indicate that there is only one nurse for every 2500 residents in India. The ratio is meagre than the rich countries with one nurse for every 150-200 residents. Studies report that the nurse-to-patient ratio is not optimal in India, leading to an increased workload and compromised patient care in some hospitals12. Regrettably, effective strategies are lacking in addressing the profound nursing shortage that threatens the quality of health care. Poor attitudes of nurses towards their profession are further contributing to compromised quality nursing care. Nurses in India fail to uphold high standards of professionalism in this era of quality assurance and patient bill of rights12.
Evidence shows that India has a shortage of more than two million nurses. In 2016, around 33,147 Indian nurses were working overseas6. Thus, the phenomenon of nursing shortage continues to lead to compromised quality nursing care offered at some hospital settings 6,12,14. Furthermore, nurses' autonomy practice is a considerable challenge in a doctor-centred health care system in India13. Literature indicates that the challenges of the nursing profession included poor quality of nursing services and working conditions, lack of autonomy, compromised nursing training in private schools, lack of standardization and regularization, unemployment, and poor salaries, particularly in the private sector14,15,16.
There is a research gap in exploring the perceptions and experiences of nurse educators' regarding the challenges and strategies of nursing education and practice in Guyana and India. Thus, this project was undertaken to explore nurse educators' perspectives regarding the challenges and strategies of nursing in both countries.
MATERIALS AND METHODS:
The following open-ended questions were asked in the interviews:
Research Question 1: Based on your experience as a present/past Principal Nursing Tutor, what are the challenges of nursing education and practice?
Research Question 2: What recommendations would you like to make to address these challenges based on your experience as a present/past Principal Nursing Tutor?
Data Collection Method
Each interview was planned at a convenient time and settings preferred by the participant. The interviews were conducted from January to March 2016. Most of the interviews were conducted at the participants' workplaces in Guyana. Interviews for the participants from India were conducted through Skype. Each interview lasted between 30 and 45 minutes and was audiotaped. Audiotapes were subsequently transcribed verbatim.
Data Analysis
The study used grounded theory and inductive thematic analysis. Three coding types were used to analyze the qualitative data: open, axial, and selective coding17. Analysis was done to identify commonalities, variations and patterns across the participants from the two countries. Themes were identified and derived a set of conclusions and recommendations for each country. The relationships among the codes and categories were presented using concepts maps and graphs via R Computer Qualitative Data Analysis (RQDA).
RESULTS:
After carefully analyzing the data collected from the interviews, the following themes were generated regarding the challenges and strategies.
a) Challenges identified in Guyana
Participants in Guyana identified the following challenges:
Need for Human Resources
All of the participants in Guyana expressed overwhelming concern regarding the lack of adequate and qualified faculty. The participants spoke of the challenges such as the need for qualified faculty, managing large classes, using ineffective teaching and learning strategies, and being unable to attend to individual students' learning needs. Some of the responses of the participants were:
"In my view, the tutor-to-student ratio is a great challenge. We have large classes. We need adequate and qualified teaching staff. The students have many issues. Some find it difficult to grasp the nursing concepts. Helping weaker students one on one basis is not possible."
"Students do not have adequate clinical supervision due to a lack of Clinical Instructors. Therefore, we (teaching staff) often depend on ward nurses for clinical supervision. However, due to nurses' shortage in the ward, this is not meeting students' needs."
Material Resources
Likewise, another significant challenge highlighted was inadequate material resources. Some of the responses of the participants were as follows.
"We need adequate equipment and supplies in the Skills Lab and the hospital settings. In addition, we have large classes, so we need adequate classroom facilities for conducive learning."
"We need textbooks and online teaching and learning resources at Nursing Schools."
"Guidelines and standards for nursing practices should be available for all the nurses in the hospital settings."
Professional Development Opportunities
The majority of the participants spoke of the need for consistent and sustainable professional development opportunities. One of the responses of the participants was:
"The Caribbean region has the nursing faculty at Master's and Doctorate levels. Therefore, consistently building the capacity of nursing tutors in Guyana is critical."
Curricular Issues
All the participants expressed that periodic curricula review was imperative for quality nursing education. In their view, the curriculum should be reviewed periodically and standardized to meet the population's growing needs in Guyana and the region. Some of the responses of the participants included:
"The faculty do not have the expertise for reviewing curricula."
b) Strategies Recommended in Guyana
Participants in Guyana recommended the following strategies to address the challenges:
Human Resources
Addressing the shortage of qualified nursing faculty is imperative. Some of the responses of the participants were:
"Consistency in offering faculty development programmes should be encouraged. Good faculty gives good outcomes. The funding must be directed to big fixes. We should foster a culture of continuity. We should consider the sustainability of the upgrading of programs."
"Specialty training in areas such as ICU, Cancer nursing, Burns care is critical. However, this will happen only if the diploma level has adequate training."
Material Resources
The majority of the participants recommended that it is critical to have an adequately equipped Skills Lab. Other resources included using technology in teaching and learning, computerizing the schools, establishing smart classrooms, providing current textbooks and journals. Some of the responses included:
"Place more emphasis on simulation labs, technology, e-textbooks, AV aids. There is a need for a common Skills lab for all health care professionals. It will be a sensible investment, the initial investment will be high, but over time, rewards will be good."
"Improve the Skills lab facilities and make it more user friendly, have someone trained, schedule students to use the Skills lab."
Curricular Review
Likewise, participants emphasized the need for the ongoing review of the RN nursing curriculum. Some responses of the participants included:
"We are closely modelling with regional curriculum; however, we need to review curriculum constantly. RN Program is required to upgrade into BSN program. That is where we need to go. We need to work together towards it."
"The best way to improve and standardize admission process is to establish a committee, which consists of members from Guyana Nursing Council, Guyana Nurses Association, Ministry of Health, Principal Tutor and other Faculty members of the programme in selecting the students. In addition, attitudes of the applicants towards the profession should be considered."
"Frequent evaluation of nursing curricula is critical. The areas of evaluation should also include the level of performance of graduates, job opportunities, and promotions."
"The faculty at nursing schools should have expertise in undertaking periodic curricular reviews."
Student Welfare
The participants highlighted that counselling sessions should be available to cope with the program's challenges and their issues. One of the participants responded:
"Lack of counselling sessions for students is a great concern. Students have social problems and family issues; they need ongoing counselling sessions."
Collaboration
The participants supported the need for collaboration with the regional and international academic and health agencies in training and sharing material and human resources.
Professional Development
Most participants in this study emphasized ongoing faculty development programmes, speciality care and advanced nursing practice.
"Consistent opportunities for faculty development at the Master's and PhD level is critical. We should collaborate with other institutions in the region for the faculty development programs. Guyana should not be isolated. We have to work together with the region. We have to lean on regional institutions for strength."
"Since the recommendation is BSc nursing degree as an entry to practice, we need to strategically think what we will do in next five years or ten years, invest in this exercise, and engage the partnerships consistently with regional institutions such as PAHO, UWI."
c) Challenges identified in India
The participants in India identified the following challenges:
Lack of Image
The participants strongly perceived that the image of the nursing profession is poor in India. Furthermore, they viewed that the scope of the nursing profession has significantly decreased in India over recent years. Some responses were:
"Lack of awareness and scope of the profession, misconception towards the profession, portraying nurses in the wrong image, treating nurses as low-profile professionals are some of the critical issues."
Another challenge is the lack of evidence-based nursing care in India."
Jobs and Salary Issues
The majority of the participants identified poor salaries as one of the major contributing factors to the nursing shortage. However, some participants perceived that government jobs were better paid than those in private sectors in India. Nevertheless, the findings revealed only a few vacancies available for government jobs in many states in India. In addition, salaries paid at the academic institutions were lesser than in the hospital settings.
Lack of Scope
The participants expressed that there is little value for nurses who have upgraded with professional qualifications. Young nursing graduates were opting to change their careers due to lack of scope and poor salaries. Professional standards were not maintained, thus leading to a poor image and lack of scope for the nursing profession. Another setback highlighted was the poor attitudes of nursing students towards the profession.
Leadership Roles, Autonomy and Advocacy
Most participants expressed a lack of autonomy, and legal empowerment was a considerable impediment. Furthermore, nurses were not actively engaged in policymaking, did not have a strong voice, and effectively practiced leadership roles in India.
Lack of Clinical Experiences
Another challenge identified was the lack of adequate opportunities for clinical experiences for nursing students and young graduates. This was due to changing demands of patients and dynamic health care modalities. For example, patients prefer out-patient care and independent care over in-patient care provided by the nurses. Nursing students were given adequate teaching in theory; however, limited clinical experiences had been provided due to a lack of support from the patients and hospital administration.
"Although simulation labs with technology were available in India, there were limited opportunities for hands-on experiences in the hospital wards. As a result, the hospitals recommended orientation programs for novice nurses to bridge the theory-practice gap."
Need for In-service Education
There were no policies with regards to in-service education for nurses. The participants stated that updating nurses' knowledge consistently by conducting CNE programmes was critical due to dynamic health care services. However, nurses who work in government hospital settings seldom had opportunities for attending in-service education sessions in India.
Nursing Professionalism
Concerns were expressed that nurses were not actively engaged in decision making at the patient care level and policymaking to take up leadership roles at the state and national levels.
d) Strategies Recommended in India
The participants in India proposed the following strategies to address the challenges:
Image of Nursing Profession
The participants recommended for broader publicity of values, standards and scope of the nursing profession in public. Participants recommended nurse engagement in decision making and autonomy. One of the participants responded as:
"I believe that one of the recommendations to meet the theory and practice gap challenges is introducing Nurse practitioner programs. We (policymakers) are hoping that the Nurse practitioner program will bring the image and offers autonomy. More positions must be created for nursing leadership roles at the policymaking level within India and the national level. We are working towards a Unique ID. Each nurse can have a unique ID to practice in any State in India without requiring individual State registrations. We also have plans for a Universal ID."
In-Service Education
The respondents indicated that nurses should be provided with more opportunities to benefit from in-service programmes and keep abreast of changing health care modalities. In addition, it was recommended that technology should be used adequately in the delivery of nursing programs.
Adequate Clinical Experiences
The findings highlighted the importance of providing nursing students with adequate opportunities for clinical experiences. Hospital administrators and the public should play a key role in supporting and providing learning opportunities for nursing students in clinical settings. In addition, teaching and learning should be supported by using adequate technology through simulation exercises in the skills lab.
Teamwork and Collaboration
The participants expressed that nursing care is teamwork and should be delivered through effective communication and ongoing collaboration among all health care professionals, including patients and families.
Salaries
The participants recommended that uniform salary criteria be offered for the nurses based on their experiences and expertise. In addition, there should be a clear distinction between different categories of nurses in terms of the designation and nature of work. Through promotions and increased allowances through motivational strategies, nurses should be recognized for their higher qualifications and working experience.
Thus, this study's findings successfully identified nursing education and practice challenges and strategies in Guyana and India.
DISCUSSION:
The data successfully developed themes and identified unique challenges affecting nursing education and practice in Guyana and India. The main themes developed under the challenges in Guyana were the need for human and material resources, professional development opportunities and curricular issues. Specific challenges highlighted included lack of qualified and adequate nursing faculty, large classes, lack of access to online learning resources and current textbooks, lack of equipment to carry out clinical procedures in the skills lab and hospital settings. Further issues identified were an inadequate number of qualified nurses to review the curricula in the nursing programmes. Another significant concern reported was that Guyanese nurses are not prepared to participate in the Caribbean Regional Examination for Nurses Registration (RENR). These findings are similar to the evidence shown in the other local studies 8,18.
Additionally, there is a critical need for Diploma nursing programmes to be upgraded to Bachelor's degree programmes in Guyana like the rest of the world. Consistent opportunities for faculty development at the Master's and PhD level is significantly lacking. The themes identified to address these challenges by the participants were an adequate supply of human and material resources, ongoing curricular reviews, student welfare services, collaboration and standardization with the regional and international training institutions, professional development opportunities. The results of this study are similar to the findings of the studies existing18, 19, 20, 21.
Likewise, themes were developed from the data regarding the challenges and strategies of nursing education and practice in India. These themes included lack of professional image, unemployment and poor salaries, lack of scope, lack of autonomy and advocacy, limited opportunities for leadership roles at the policymaking level, inadequate clinical experiences, need for in-service education and maintaining professional standards. These findings support the existing reports6,12,13. Themes identified to address these challenges included: improving the professional standards and image of the nursing profession, enhancing autonomy, fostering in-service education, providing adequate clinical experiences, teamwork and collaboration among health care professionals, and improved salaries. This study data corresponds with the studies done in India6,12,14.
The researcher further recommended that the governments of Guyana and India immediately set realistic budgets and strategic five-year plans to achieve these goals. The Government of Guyana must, without delay, reduce the "push" factors in nursing emigration, especially salaries. The Government of Guyana should embark on a strategic plan to have all nursing programs accredited with the Caribbean region. The Ministry of Public Health, the University of Guyana, and the Ministry of Education and NGO's should collaborate to foster standards in nursing education and practice in Guyana. Regional and international Nursing organizations should actively support sharing human and material resources with less developed countries, including sponsoring sabbaticals in Guyana and offering online accredited and degree programmes.
The University of Guyana, in collaboration with the PAHO, Saint Joseph University, USA and the Ministry of Health, launched a Bachelor's degree in Mental Health Nursing in July 2021. This programme is aimed to strengthen the mental health care services and research capacity in the speciality area of Menta Health nursing22.
In 2018, in collaboration with the PAHO and the Government of Brazil, the Government of Guyana offered eight masters and five doctoral degree Scholarships for Guyanese nurses. This initiative had strengthened the human resource development plans in the health care system in Guyana23.
Several nursing tutors in Guyana were offered Certificate programmes in Nursing Education from the University of Miami to advance their competencies and skills in nursing education. This project which began in 2016, was a collaborative approach from the Pan American Health Organization and the World Health Organization (PAHO WHO)24, 25.
Additionally, in 2016, another milestone was achieved in the nursing fraternity in Guyana as a Bachelor's degree in Emergency nursing program was launched for nurses working at the Georgetown Public Hospital Corporation (GPHC), the first of its kind in the region. This initiative came to reality as a joint effort among the Georgetown Public Hospital Corporation, Vanderbilt University Medical Center, and the University of Guyana26.
Besides, in 2011, a cohort of registered nurses working in the referral hospitals was trained in the Critical Care Nursing training program. This project was a collaborative approach among the Ministry of Public Health's Health Sciences and Education Faculty, the Pan American Health Organization and the World Health Organization (PAHO/WHO), and St. Joseph's University Connecticut, United States of America27.
The Indian Nursing Council in India embarked few significant projects during the last five years. One of these initiatives was establishing a two-year Nurse practitioners program in 201727. The government of India established this program to make significant contributions to tertiary care services both in the public and private sectors. This initiative aimed to prepare advanced nurse practitioners who can provide cost-effective, competent, safe, and quality-driven specialized nursing care to patients in various settings in tertiary care centres. This program is a competency-based training program that offers nurses legally bound nursing practice28, 29.
According to a recent report, nurses are still working for far lower salaries. This situation continues despite the order of the Supreme Court of India to private establishments to pay a minimum pay of Rs.20,000/- per month for nurses working in more than less than 50 bedded health care facilities. However, the recommendation has not been implemented by the majority of the private hospital settings30.
RELEVANCE FOR NURSING:
The findings of this study identified specific critical challenges and strategies of nursing education and practice in Guyana and India. Thus, this study successfully filled the research gap and established the scientific data that can be utilized in policymaking to enhance nursing education and practice standards in Guyana and India.
RECOMMENDATIONS:
The researcher made recommendations that the governments of Guyana and India immediately set realistic budgets and strategic five-year plans to achieve these goals. The Government of Guyana must, without delay, reduce the "push" factors in nursing emigration, especially salaries. The Government of Guyana should embark on a strategic plan to have all nursing education accredited with the rest of the Caribbean region. The Ministry of Public Health, the University of Guyana, and the Ministry of Education and NGO's should collaborate to foster standards in nursing education and practice in Guyana. Regional and international Nursing organizations should actively support the sharing of nurse educators with less developed countries, including sponsoring sabbaticals in Guyana and offering online accredited and degree programmes.
The quality and quantity of nurse training should be improved in India. In addition, the government of India should offer a uniform cadre structure, high pay, defined carrier path, career progression, state-of-the-art working conditions, flexible working hours, and safety measures for nurses in government and private healthcare facilities. It is pivotal to establish adequate representation of nurses in policy and decision-making at the institute, state, and national level in India16.
Further research should be conducted on identifying 'attainable,' 'cost-effective,' and 'innovative' approaches to address the nursing education and practice needs.
CONCLUSION:
In conclusion, the study reiterated some critical elements impeding quality nursing education, practice, and patient care services in both countries over the past few decades. The study urges further research on identifying 'attainable,' 'cost-effective,' and 'innovative' approaches to address nursing education and practice needs. The challenge is to appropriately incorporate and urgently engage national, regional, and international agencies in combating the global shortage of human and material resources while upholding the nursing profession's values. Finally, the project findings supported the existing literature that providing "quality nursing education" and generating a "quality nursing working force" was pivotal for delivering "quality patient care services."
ACKNOWLEDGMENTS:
The author would like to thank all the participants for their kind support in conducting this study successfully.
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Received on 23.09.2021 Modified on 21.11.2021
Accepted on 10.01.2022 ©AandV Publications All right reserved
Res. J. Humanities and Social Sciences. 2022;13(1):69-76.
DOI: 10.52711/2321-5828.2022.00012