|Year : 2016 | Volume
| Issue : 5 | Page : 498-503
An attempt for empowering education: A qualitative study of in-service training of nursing personnel
Mahmood Chaghari1, Abbas Ebadi2, Ahmad Ameryoun3, Mohsen Safari1
1 Faculty of Health, Baqiyatallah University of Medical Sciences, Tehran, Iran
2 Behavioral Sciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
3 Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
|Date of Submission||15-Oct-2015|
|Date of Acceptance||26-Apr-2016|
|Date of Web Publication||4-Nov-2016|
Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Background: In-service training of nursing personnel has a significant role in increasing the empowerment of nurses and promotion of the quality of health services. The objective of this study is to identify and explain the process of in-service training of nursing personnel in the hospitals affiliated with Baqiyatallah University of Medical Sciences in Tehran.
Materials and Methods: The present study employed a qualitative approach using Corbin and Strauss method (2008) in 2015, and examined the viewpoints and experiences of 35 nurses, nurse managers, and educational managers with the in-service education of nursing staffs. According to this method, comparisons, asking questions, flip-flop technique, depicting personal experiences, and raising red flag were used for data analysis.
Results: In this study, five major themes including unsuccessful mandatory education, empowering education, organizational challenges, weakness in the educational management, and educational-job resiliency were derived from the results. Unsuccessful mandatory education was the main concern of participants and empowering education was the core category derived from this study.
Conclusions: Empowering education emphasizes the practice-oriented and self-directed training. It is an applied education, is participation-oriented, facilitates job functions, and is based on exploration.
Keywords: Empowering education, grounded theory, in-service training, job resiliency, nursing personnel
|How to cite this article:|
Chaghari M, Ebadi A, Ameryoun A, Safari M. An attempt for empowering education: A qualitative study of in-service training of nursing personnel. Iranian J Nursing Midwifery Res 2016;21:498-503
|How to cite this URL:|
Chaghari M, Ebadi A, Ameryoun A, Safari M. An attempt for empowering education: A qualitative study of in-service training of nursing personnel. Iranian J Nursing Midwifery Res [serial online] 2016 [cited 2019 Sep 16];21:498-503. Available from: http://www.ijnmrjournal.net/text.asp?2016/21/5/498/193404
| Introduction|| |
Training of personnel is an efficient guarantee for constant development of organizations. It is an important approach by which human resources boost their capabilities.  Employees have an important role in the growth and development of an organization, and empowering the employees through in-service training leads to development and success of an organization.  In-service education of nursing personnel is highly significant and very effective for increasing the quality of hospital services. Studies show that a significant relationship exists among training the nursing personnel and medical results and outputs.  The need to increase the efficiency and effectiveness is undeniable in both preservice and in-service education.  Considering the effective in-service education for empowering nurses appears necessary for the constant changes in medical services and cares. With regards to the increasing progress of science and medical technology, it seems necessary that the care processes of patients are updated.  The previous studies conducted on the in-service education of nursing personnel show the lack of follow-up evaluation and provide little evidence of their effectiveness.  The effectiveness of some in-service educational programs on promotion of patient care is not properly approved.  The need to increase the capacity and improve the educational results and outputs along with significant changes in the medical care justifies the need for development and administration of new medical models for the nursing personnel. 
The accreditation council for continuing medical education (ACCME) believes that, by reconstruction and development of in-service education, the quality of hospital care can be improved. 
Background in Iran
In-service training of nursing personnel was mainly conducted by the Ministry of health and medical universities until 2012. After 2012, with the implementation of accreditation standards in Iranian hospitals, the education of nursing staffs underwent a considerable evolution, and a major part of it was devolved to the hospitals.  Hospitals were obliged to hold annual educational courses and workshops on cardiopulmonary resuscitation, patient's rights, communicative and behavioral skills, patient's safety, infection control, environmental sanitation, job health and immunity, risk management and crisis management, as well as to conduct the required educations required by the nursing personnel in different divisions of the hospital separately based on a needs assessment approach.  The in-service educational program of nurses in Iran had no significant effect on the professional output of nurses and promotion of nursing care quality up to 2012.  The main point for the success of in-service training programs of nurses is scrutinizing and identification of the grounds, processes, and interactions of nurses with the personnel's education system. Hence, the present study is aimed to investigate this issue in the hospitals affiliated with the Baqiyatallah University of Medical Sciences.
Purpose of the study
The purpose of this qualitative study was to explain the process of in-service education of nursing personnel in the hospitals affiliated with the Medical University of Baqiyatallah, as well as the identification of the grounds, processes, and interactions of nurses with the personnel's education system to explore the main concern of the participants along with barriers and facilitators in order to design the optimal model of nursing staff education.
| Materials and Methods|| |
The present study is derived from a PhD thesis submitted in 2015 based on the qualitative approach of the grounded theory and Corbin's method (2008).
The statistical population of this study included the hospitals affiliated with the Baqiyatallah University of Medical Sciences in Tehran. The samples included 35 personnel including nurses, supervisors, nursing managers, educational managers, and hospital managers. At the first stage, samples were selected using purposeful sampling method, and at the second stage, the samples were theoretically selected based on emerging concepts aimed at analyzing a range of consequent topics that take the maximum diversity into account. ,
Data collection and analysis
The data were collected using semi-structured interviews, observation, field notes, as well as by studying the documents and evidences. In total, 42 interviews (2 interviews for some of the participants) were conducted in three hospitals with an average duration of 60 min for every interview. The participants were asked to describe their experiences and perceptions related to in-service education of nursing staff. Then, the interviews were directed according to the responses of participants. The interviews were recorded with a digital recorder and were listened to several times and transcribed on the same day. The transcriptions were considered as the main data of research. The main researcher attended 21 educational programs and took field notes. In addition, he attended different parts of the hospitals in 34 sessions and observed the operations and application of the educational materials and took notes. Moreover, the documents and evidences including the policies and guidelines of the hospitals were used. For collecting deeper and better data, the researcher found a part-time job in one of the hospitals and observed the process of education, educational programs, and the application of educational material while working inside and took notes. The data were analyzed using the Corbin and Strauss method (2008). Using this method, various techniques including comparisons, asking questions and thinking about different connotations of a concept, flip-flop technique, depicting personal experiences, and raising red flag were used to data analysis.  Comparisons were used for comparing events and phenomena with each other for their similarities or differences. Continued asking questions assessed the quiddity of data and were followed issues such as: who, what, when, where, how and with what consequences. Waving the red flag followed that in which conditions a phenomenon always happened or did not happen.  For coding data, MAXQDA-10 was used. Four types of coding were applied in this study, namely, coding for concepts, coding for context, coding for process, and coding for outcome. Hence, after the categorization and classification of codes, the main themes evolved, which were then classified in to three dimensions of context, process, and outcome. To assure the accuracy of research and reliability of results, the strategies provided by Lincoln were used.  In terms of the credibility of research, the researcher was constantly involved with the data; moreover, data were confirmed by the participants, research team, and two external experts. To achieve dependability, two members of the research team coded the interviews separately and they compared their drafts and resolved the disagreements. For confirmability of the research, sufficient time (2 years) was devoted to data collection, notation, and analysis, and each stage was conducted very carefully. For transferability, the collected data and information were reviewed and confirmed by two experts.
The study was approved by the ethics committee of the Baqiyatallah University of Medical Sciences; the participants signed an informed consent form to participate in the study. They were also assured of the confidentiality of personal information, their right to quit the study at any time, not recording any part of the interview, and the confidentiality of interviews.
| Results|| |
This study included 20 nurses, 2 supervisors, 3 nurse managers, 6 educational managers, and 4 hospital managers. The sample consisted of 17 males and 18 females at the age range of 27-51 years, with an average of 39.08 years. Their level of education varied from Bachelor to PhD. Regarding the type of employment, 9 participants were extra-hours employees, 8 were contractual employees, and 18 were formal employees. After analyzing the interviews, 1186 codes without overlap and 568 overlapping codes were identified at the first level. In this study, five major themes, 10 main categories, and 22 subcategories were found [Table 1]. The main themes included unsuccessful-mandatory education, empowering education, organizational challenges, weakness of educational management, and educational-job resiliency. Unsuccessful-mandatory education was the main concern of participants, and empowerment training was the core variable derived from data.
The unsuccessful-mandatory education addresses the compulsory education that performs the shape and manifest of education and has weak efficiency; it has not the necessary effectiveness in the teaching and applying the materials by the learners. One of the educational manager stated "We are working on the surface … education is not an obligatory subject … education must be effective at the first hand i.e., it should give the necessary feedback to the personnel … unfortunately I feel that we have problems both in the learning process and in the administration process …" (Educational manager: 3, 42 year-old female).
Field notes and observations confirmed the unsuccessful and mandatory education. Nurses did not actively participate in training programs and teachers frequently expressed phrases such as "Why is participation so missing" and "I see that most of you are asleep."
In the unsuccessful-mandatory education, lack of organizational and professional incentives and encouragement as well as the weakness of educational culture in the organization challenge the effectiveness of nursing staff education. The concept of unsuccessful education was observed in this study to be the main concern of participants. One of the nurses stated "The educational culture and learning are very poor in our hospital … however trainings intervene with job processes of personnel and unsuccessful application of method and the content of education puts them into many problems … education must be useful and effective" (Nurse 5, 29-year-old female).
During the research, the participants pointed at unsuccessful-mandatory education and were hopeful of achieving effective and successful education. The key participants (nurses) believed to spontaneity and applicability of educations. One of the nurses stated "They should teach subjects to the nurses that be of use in the operations and medical care, not just a bunch of theories … the nurse should be able to apply them in her work … morning report classes are quite beneficiary for example … because its tangible, it increases the practical knowledge of the nurse" (Nurse 15, 34-year-old male).
One of the supervisors stated "Nurses should determine the educational contents and didactic subjects … educational managers should apply the idea of nurses for the selection of subjects … it should be self-motivated … it should create incentives for the nurses to follow learning …. Education must be given up classic methods and obligation" (Matron 2, 36-year-old female).
Field notes and observations showed that the nurses actively participate in practical and self-directed education. Welcoming trainers with medical experience, the interest of nurses toward indirect education, welcoming monitoring and receiving feedback, and the interest of nurses in clinical education are some of the examples of this issue. The interest of nurses to practical and self-directed learning, directed educational managers to spontaneous and applied educations. Self-directed and applied education led the researchers to empowerment training. Empowerment training in this study was selected as the core variable because all other variables were focused on it and the common strategy of participants was to achieve educational success.
Some of the organizational procedures in the studied hospitals were conflicting with the nature and goals of educational programs and prevented from training success. Some of these factors are financial constraints, lack of nurses, and the conflicts caused by different management divisions against education. One of the educational supervisors stated "The most important problem is the conflict among middle management and education. The human resource management has determined the limitation of working hours … the head nurse cannot have more personnel in the education courses … The management team is opposed to the raise of salaries, management wants the minimum workforce with maximum output … these are against education …" (Educational supervisor No: 1, 42-year-old female).
Furthermore, organizational challenges indicate that the framework of working processes in the studied hospitals is against the nature and goals of nursing staff educations. One of the nursing managers states that "Diagnosis and medical processes are not congruent with educations … The number of surgery operations, MRI, CT scan, and Blood tests do not match with the number of nurses. ICU admits cases are abundant in the divisions … these are not consistent with educational goals" (Nursing manager No: 2, 47-year-old male). The concept of organizational challenges is classified as a context-related concept.
Weakness in educational management
The concept of weakness in educational management refers to the deficiencies that are related to the educational process of nursing personnel including needs assessment, evaluation, and providing educational feedback. It also indicates the incompetency related to organizational education processes such as intraorganizational education, general education, and extraorganizational education. Regarding the weakness of educational needs assessment, one of the nurses stated "Some of the educational topics are not in line with the needs of personnel … needs assessment is done but not correctly, and again no good planning is done for the identified needs … in the end, the programs are conducted which are not consistent with the needs of personnel …" (Nurse No: 18, 28-year-old female).
The nursing personnel in the wake of dissatisfaction with the unsuccessful-mandatory education and access to the empowering education, on the one hand, are faced with the lack of appropriate conditions and substrates as a result of organizational challenges and weaknesses in educational management, and on the other hand, are faced with inappropriate governing conditions including hospital's educational policies and unfavorable cross-training rules. In such a condition, they have to endure obligatory obedience and adapt to the present situation. In this way, nursing staffs have achieved educational and job resiliency. One of the nurses stated that "hospital management is not supportive of the nurse … It does not provide the necessary ground for supporting the nurse such as raising the salary, increasing the number of personnel … hospital management just wants obedience from the nurse …" (Nurse No: 10, 38-year-old male).
Another nurse stated "A nurse has no choice but to obey … We have to participate in the educations and apply them … we are not satisfied with the present condition … job pressure is too much … we are doing our best but the job condition is not good at all … we have to adapt" (Nurse No: 19, 36-year-old female).
The general processes and the main concepts of in-service education of nursing personnel of the hospitals affiliated with the Baqiyatallah University of Medical Sciences are presented in [Figure 1].
|Figure 1: The general process and main concepts of in-service education of nursing personnel of the BMSU hospitals|
Click here to view
[Figure 1] shows that educational deficiency in addition to deterrents such as poor educational culture, along with mandatory education leads to the unsuccessful-mandatory education. Unsuccessful-mandatory education is the main concern of process owners (nurses) and they seek to remove it by practical and self-directed education. Participants indeed seek empowering education. Contextual factors such as poor educational management and organizational challenges are the barriers that conflict with empowering education. As a result, process owners turn to educational governance coincidence and work accommodation. Therefore, the nurses attained educational-job resiliency.
| Discussion|| |
In-service training includes programmed educational activities that seek the promotion of scientific and experimental knowledge of professional nurses in the fields of performance, management, and research, which is in line with the development and improvement of public health.  In addition to increasing the theoretical knowledge, such professional trainings increase the technical and qualitative ability of services and lead to innovation.  The results of the present study showed that the nursing personnel seek applied and practical education. The interest of nursing personnel to specialized professional education, welcoming the trainers with medical experience, and morning report educational programs resulted to the concept of optimality of practical education. The gap between professional skills of the personnel and the required skills for the job leads to job reluctance. In-service education can reduce this gap and increase the incentives and sense of organizational belonging.  The results obtained by Rowden and Conine  and Sahinidis and Bouris  showed that the effectiveness of educational programs on promoting the professional skills of personnel results in job commitment and employee satisfaction; employees will feel that they are important to the organization and their attachment to the organization will increase. In the present study, nurses were indirectly demanding more attention through providing the grounds for applied and practical education.
Clinical supervision of nursing improves the quality of services and develops the medical and applied skills of the nurses.  Our findings also showed that educational managers believe that for promoting the effectiveness of nursing in-service education, performance assessment and reflection of the results should be done. Nursing personnel were also were embracing this.
Self-directed learning was another dimension of empowering education in the present study. Nursing personnel were seeking results, attitude, exploration, and participation in the educational programs. The self-directed learning follows the principles of adult's learning. In self-directed learning, the learning initiative is in the hands of learners; research, exploration, and commitment are the basis of education and learning.  Self-directed learning is introduced as a method for lifelong learning in medical education.  In self-directed learning, the learners self-learn the necessary subjects and through different methods.  According to ͺenyuva and Kaya, nurses have shown a considerable interest to self-directed learning in the field of web-based learning. Pinheiro and Sardo  also showed that self-directed education techniques have an effective role in expanding the educational skills of health professionals. Similarly, in the present study, nurses were seeking the development of their professional skills through self-directed learning methods. Evidences show that those who initiate their own learning (active learners) obtain better results and use their learnings more and better, compared to passive learners. 
Another major theme derived from our data is educational-job resiliency, which indicated the consequence of action-interactions. Nursing personnel were attempting to achieve empowering techniques, however due to organizational challenges, the necessary conditions and grounds to achieve this aim was not possible. The weak points in educational management was another field variable that intensifies the challenges; therefore, nurses faced with unfavorable educational governing conditions on one hand, and were obliged to obey the educational principles of the organization on the other hand. These issues led the nurses into some kind of employment and training resiliency. From a sociological point of view, resiliency was a dynamic process to adapt with stressful events, indicating the ability of people in having successful performance when faced with different events.  Social resilience refers to the social ability to cope with difficulties and unpleasant events without endangering social values.  Reyes et al.  showed that resilience neutralizes the negative effects of stress and has an effective role in the professional and educational life of the nurses. This finding is consistent with our result. Kim and Windsor  studied work-life balance in firstline nurse mangers and found that the firstline nurse mangers use action-interactions such as "positive thinking," "flexibility," "assuming responsibility," and "separating work and life" to achieve the dynamic and reflective process.
However, in the present study, enduring job stress and job involvement in addition to coping with organizational and governance conditions led the nurses to job resiliency.  A study by Jackson et al.  showed that the strategy of nurses toward workplace adversity was personal resilience, which can be improved by maintaining positivity, developing emotional insight, and achieving life balance and spirituality. Similarly, the present study also noted that job resiliency is a strategy used by nurses in unpleasant working conditions, which is realized through obligatory obedience.
| Conclusion|| |
Empowering education is one of the in-service education models for nursing personnel that emphasizes self-directive learning and practical education. Empowerment training is result-oriented, participatory, and attitudinal, and is based on exploration, research, and commitment. It facilitates job duties and increases the professional skills of the nurses. Unsuitable organizational ground is an obstacle for the implementation and success of empowering education. Unsuitable grounds in an organization leads to nursing job and educational resiliency, which in turn results in increment of nurse's compatibility with the employment and educational conditions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zheng H. Analysis of staff training needs at Xiahua Factory based on OTP mode. In: International Conference on Economic Management and Social Science (EMSS 2014). Xi′an, China: Atlantis Press; 2014. pp. 133-7.
Mokhtarzadegan M, Amini M, Takmil F, Adamiat M, Sarveravan P. Inservice trainings for Shiraz University of Medical Sciences employees: Effectiveness assessment by using the CIPP model. J Adv Med Educ Prof 2015;3:77-83.
Bluestone J, Johnson P, Fullerton J, Carr C, Alderman J, Bontempo J. Effective in-service training design and delivery: Evidence from an integrative literature review. Human resources for health, 2013: Availaible from: http://www.human-resources-health.com/content/11/1/51
. [Last accessed on 2015 Jun 12].
Ajani K, Moez S. Gap between knowledge and practice in nursing. Procedia Soc Behav Sci 2011;15:3927-31.
Aylward S, Stolee P, Keat N, Johncox V. Effectiveness of continuing education in long-term care: A literature review. Gerontologist 2003;43:259-71.
Fisher C, Sadera W. Comparing student learning and satisfaction between learning environments in continuing medical education. Int J Instructional Technol Distance Learning 2011;8:29-41.
Tanner CA. Transforming prelicensure nursing education: Preparing the new nurse to meet emerging health care needs. Nurs Educ Perspect 2010;31:347-53.
Jafari G,Khalifegari S, Danaei Kh, Dolatshahi P, Ramezani M, Roohparvar R, et al
. Hospital Accreditation Standards in Iran. 1 st
ed. Tehran: Seda; 2010 .
Ramezani M, Jafari G, Dolatshahi P, Mehrabifar H, Khalifegari S, Danaei Kh, et al
. Guideline for Hospital Standard Accreditation in Iran. Ministry of Health Care, editor. 1 st
ed. Tehran: IRN.MHCME; 2013.
Monajati F, Moradi A, Khayeri B. The relationship between in-service training for occupational outcomes. Iran J Med Educ 2013;14:495-506. [Persian]
Corbin J, Staruss A. Bascs of Qualitative Research. 3 rd
ed. London: SAGE Publication; 2008.
Streubert HJ, Carpenter DR. Qualitative Research in Nursing: Advancing the Humanistic Imperative. 5 th
ed. Philadelphia, PA: Lippincott; 2011.
Polit DF, Hungler BP. Nursing Research: Principles and Methods. 7 th
ed. Philadelphia, PA: Lippincott; 2006.
Furze G, Pearcey P. Continuing education in nursing: A review of the literature. J Adv Nurs 1999;29:355-63.
Jalali G, Berlian AR. The effect of technical training courses to improve the skill level of after sale services staffs of automotive industry. J Eng Educ Iran 2014;16:117-34. [Persian]
Rowden R, Conine CT. The impact of workplace learning and job satisfaction in small US commercial banks. J Workplace Learning 2005;17:215-30.
Sahinidis S, Bouris J. Employee perceived training effectiveness relationship to employee attitudes. J Eur Industrial Training 2008;32:63-76.
Cruz S, Carvalho L, Sousa P. Clinical supervision in nursing: The (un)known phenomenon. Procedia Soc Behav Sci 2012;69:864-73.
Knowles M. Self-directed Learning: A Guide for Learners and Teachers. New York: NY: Association Press; 1975.
Murad M, Varkey P. Self-directed learning in health professions education. Ann Acad Med Singapore 2008;37:580-90.
Lenny CH, Peng YQ. Efficacies of different methods of teaching transcultural nursing practice in China. Chin Nurs Res 2014;1:17-24.
ªenyuva E, Kaya H. Effect self directed learning readiness of nursing students of the web based learning. Proc Social Behav Sci 2013;152:386-92.
Pinheiro A, Sardo D. Developing educational skills in the health professionals using SPIN technique. Procedia Social Behav Sci 2015;171:1223-8.
Wolin S, Wolin S. The Resilient Self: How Survivors of Troubled Families Rise Above Adversity. 1 st
ed. New York: Villard; 1993.
Friedland N. The "elusive" concept of social resilience. In: Friedland N, Arian A, Kirschenbau A, Karin A, editors. The Concept of Social Resilience. Haifa: The Technion: Samuel Neaman Institute (Hebrew); 2005.
Reyes A, Andrusyszyn MA, Iwasiw C, Forchuk C, Babenko-Mould Y. Resilience in nursing education: An integrative review. J Nurs Educ 2015;54:438-44.
Kim M, Windsor C. Resilience and work-life balance in first-line urse manager. Asian Nurs Res (Korean Soc Nurs Sci) 2015;9:21-7.
Jackson D, Firtko A, Edenborough M. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: A literature review. J Adv Nurs 2007;60:1-9.