1 Title From hospital based training to tertiary education: issues concerning an initial implementation of newnursing education policy Author(s) Yeung, Hiu-hung.; 楊 曉 紅. Citation Issued Date 2000 URL Rights The author retains all proprietary rights, (such as patent rights) and the right to use in future works.
2 From_Hospital Based_raiin to Tertiary Education: Issues Concerning An Initial Implementation of New NnrgEducation Policy By Yeung Hiu Hung Dissertation presented in part fulfillment ofthe requirements of the degree ofmaster Education, the University ofhong Kong.:\ c. : ':-- 'a 2000 The University offlong Kong
3 Declaration I hereby declare that this dìssertation represents my own work and that ìt has not been previously submitted to this University or any other institution in application for admission to a degree, diploma or other qualifications. /1 / '7)I4( ( «f jígust2000 6r L7 i --- i
4 1 AÇKNOWLEDGMENTS Sincere thanks to my supervisor, Associate Professor Colin W. Evers, for his warmth, encouragement, guidance and supervision. I am grateful for his consistently positive and supportive approach throughout my Master of Education study in the last two years. In particular I would like to thank my informants for their resourceful opinions and enlightenment, without whom this research would not have been possible. I express my gratitude to the following persons who generously granted me time for my interviews: Professor Allen Chang Ms. Susice Lum Ms. Herima Ho Ms. Lillian Ho Ms. Fiona Fung Mr. William Poon Ms. Ma Wai Ling Ms. Cindy Cheung Special thanks to my daughter, husband, and parents for their understanding, encouragement, endless support and love. ii --
5 THE UNIVERSITY OF HONG KONG LIBRARIES Thesis Collection Deposited by the Author
6 Abstract In July 1999, The Hospital Authority announced that hospital-based nursìng schools would suspend recruitment of student nurses as a result of a decision to upgrade basic nursing educatìon to degree level correspondingly. A proposal has been made to the Government to increase first year first degree nursing places from the current 200 to a total of 400 as an interim measure with 600 being the longer-term target. The employment category of Health Care Assistant was introduced to relieve nurses from low complexity nursing duties in orderto conserve ofnursing manpower. Consequently, it was recommended that a total of I 72 Nurse Educators should be deployed to the clìnìcal areas. The aim of this study is to understand what is involved in the implementation of the nursing education reform of shifting nurse education from hospital based programs to university. Eight informants who either participated in the policy making, arid implementation or were affected by it, were interviewed. The main site where the Implementation was studied in detail and reported on, was a school of nursing located wìthin a large Government hospital. This was one of the schools marked for closure, with the hospital to receive new university educated nurses. Key themes relating to the 'n
7 new policy were identified, summarized and analyzed within the following categories: the rational and political reasons for change, universìty programs and the question of clinical practice, manpower ìssues, implementation strategy and deployment of nurse educator. iv
8 Table of Contents Çpter One: Introduction i i. Introduction 2. The Background and Development ofnursing Education in 2 Hong Kong: An Overview 2.1.The Development ofnursing Education in a Historical 3 Perspective FlorenceNightingale Study-hour System Preliminary Training Study-block System Nursing Board ofhong Kong Teaching Staff S 3. The Nursing Education System of Other Countries IO i i The Nursing Education System in United Kingdom The Nursing Education System in Australia Current Development ofnursing Education in Hong Kong The Significance ofthe Study and Research Questions The Aim ofthe Study The Scope ofthe Study The Research Questions 21 Çpter Two: Theoretical Framework 22 i. Iniroduction Definition ofpolicy The Models ofpolicy Process A Model ofpolicy Anaiysìs Models ofpolicy Making Rational Policy-making Liniitation ofrational Policy-making The Administrative Model: a Satisficing Strategy The Incremental Model The Mixed Scanning Model: an Adaptive Strategy The Garbage-can Model: Irrational Decision Making The Appropriate Model -- Coherent Constrain Satisfaction 37 Model Some Constrains of Polìcy Makìng 38 6.l.1Values Politics Ethical Issue in Policy Making Coherent Constraint Satisficing Approach Conclusion 46
9 Chpter Three:ResearchMethodology 48 Introduction Methods ofdata Collection Secondary Data Interview I.Informants Semi-structured Interview Note Taking and Tape Recording Informal Interview Reliabìlity and. Validity Analysis Methods Ethical Considerations The Limitations of Study 61 Chapr Four: Results of the Empirical Study 62 Introduction: Themes Concerning the Reasons for Transformation ofnursing 65 Education 2.1 Upgrade Nursing Education Enhance Professional Status and Image The Roles ofnurses Themes Concerning the University Lack ofclinical Practice 69 and Experience 4. Implementation Strategy: Implementation without Consultation Lack oflnvolvement During the Change Process Shortage offront Line Nursing Staff The Leanthig Need of Exìsting Hospìtal Based Nursing 83 Students Are Not Addressed 8. Why introduce Health care assistant (HCA) The Implications for Deployment of Teaching Staff Loss ofequilibriumílow Moral and Loss the Job Security Adaptation: actìve movers and passive responder Passive responders Active mover 93 Chapter Five:Discussion and Implication Rational Reasons for Nursing Education Reform Political Reasons ofnursing Education Reform Stafflmplications StaffMix: Replace Student Nurse with Health Care 107 Assistant vi
10 3 2 Does the current Low Hospital Staff Tuimover Rate i 09 Provide a 'Good Chance' for Implementation of New Nursing Education Policy? 3.3 Suspend the Hospital Based Program Prior to the i 12 Expansion of Tertiary Program 4. Implications for clinical practice i The Value and Culture Influence in Nursing Education 114 Reform 4.2 Supernumerary Status in Clinical Practice and Its 119 Implications 4.3 An Example: Project 2000 in United Kingdom The Importance ofclinical Practice and Experience The Implications for Deployment of Teaching Staff 125 Chapter Six: Conclusion 129 Reference 137 vil
11 Abbreviations AHKNS --- Association of Hong Kong Nursing Staff DII --- Department of Health EN Enrolled Nurse GMN --- General Manger (Nursing) HA --- Hospital Authority HCA --- Health Care Assistant HCE --- Hospital Chief Executive NBHK --- Nursing Board ofhong Kong NE --- Nurse Educator NO --- Nursing Officer RN --- Regìstered Nurse SEMN --- Senior Executive Manager (Nursing) STN --- Student Nurse UGC --- University Grants Committee WM --- Ward Manger VI"
12 Chapter One: Introduction 1. Introduction The ultimate goal of the nursing profession is to provide the highest quality services to the individuals whom it serves. To thìs end, nursing has continually struggled to develop a scìentific body of knowledge that underpins and guides its practìce. The past decade has been a time of significant and continuing change for up-grading mirsìng education to tertìaiy level in Hong Kong. The Hospìtal Authority (HA) announced the new nursing education policy on July including that its i i hospital based nursing schools, except the one at Queen Elizabeth Hospital jointly by Polytechnìc University, would suspend recruitment ofnurses. At the sanie time. HA proposed for the Government to "expand the first year first degree nursing places from the current 200 to a total of 400 as an interim measure towards an ultimate number of 600 required in the longer term" (HA, I 999, p.2). The new policy aims at improving the quality of nurses so as to enhance better patient care. HA said that the staff turnover rate was low and HA had a manpower surplus so it was a good chance to implement new policy. On the other hand, the nurses and patients claimed that there was a serious shortage of front line staff especially when "cheap manpower-student nurses" were cut. i
13 The purpose of this chapter is try to provide an overview of the development of 1-Jong Kong nursing education in a historical aspect to service as a foundation for Ñrther discussion of the nursing education reform. The ever ìncreasing demands placed on the nurse's role have lead to the formulation of a variety ofnursing education programs each with its own purpose. Nursing education programs have included: the basic training course for RN and EN, midwife nurse training, continuing nursing education programs, inservìce education courses, degree programs and post-graduate programs. In this chapter, development history of the nursing education and different types of nursing training program are explored to provide a general understanding of nursing education. In consideration of the complexity of nursing education as a specialized field, only the programs which prepare graduates for licensure as regìstered nurses wìll be explored. This is because the majority of the nursing workforce in Hong Kong are RNs and only the RN traìnìng is to be tmnsferred to tertiary institutions. 2. The Background and Development of Nuirsg Education in Hone Kong: An Overview Hong Kong was a colony of the United Kingdom for loo years. During the period of colonization, the health care system and nursing education in Hong Kong followed the British model. The Nightingale apprenticeship system with ìts emphasis on the service needs of the institution had persisted for almost a century. Traditional nurse training
14 requires student nurses to be responsible for providing directed nursing care in hospital, while undertaking the nursing training course all under the supervision of a qualified nurse. Nurse practitioners need to be, and are expected to be, skilled in a vast number of areas arid are expected to synthesize their base of increasing knowledge to provide maximum benefit to the patìents. In the traditional training system, a conflict between the needs of the service and the educational needs of the student is inevitable. At the same time, Hong Kong as an international city has already established networking with other countries to share experiences and information. A lot of nurses have studied aboard and received higher education in other countries, e.g. Australia and have come back with a wider variation ìn the experience and concepts of nursing education. Health care practice is influenced by socìo-economic-political contexts, and so is nursing practice. Recently, Hong Kong nursing education system has been undergoing rapid and unprecedented changes The Development of Nursillg Education in a Historical Perspective During the period of 100 years colonization, health care service and education were part ofthe systems ofeconomic, social and political relations imposed by the coloniser. These policìes were reinforced by the adoption ofthe colonizer's language as the only or major medium of instruction, the recruitment of expatriate staff from the colonizer and their 3
15 domination at the senior administration level. Similar to other educational systems in Hong Kong, the health care system and nursing educatìon are greatly influenced by UK and follow the Nightingale model Florence Nightingale Florence Nightingale ( ), the mother ofnursing professionals, was a very well educated, wealthy, and socially prominent English woman. She was sensitive to the poor condìtìon in hospitals and other health and welfare facilities. Her years of nursing experience as a hospital superintent and her intense research on health care all helped her to develop an entirely new concept of nursing. She felt strongly that both education and practice were necessary in order to function properly in the nurse's role. She established a school of nursìng at St. Thomas Hospital ìn London, England. Nightingale's three-year diploma program became the model for nursing education thoughout the world and of course included Hong Kong (Lee, I 987). By the beginnìng of the twentieth century, there were two government hospìtals to provide the health care needs of the colony. These two hospitals were also the foundation for nursing training. They saw the establishment of a nursing school as an economic advantageous way of provìding a nursing service. The hospital administrators found that the students in framing were not only easy to be disciplined arid controlled than hired nurses, but also more satisfactory as providers of service.
16 2.1.2 Study-hour_System The first school of nursing in Hong Kong was opened in The English language was the medium of instruction. Almost all the nursing sisters were English even though a large proportion of the patients were Chinese. The trainees were called probation nurses and they put in long hours each day studying and working (Lee. 1987). The probationer nurses were responsible for providing most of the directed nursing care in hospital while undertaking the nursing training course under the supervision of English nursing sisters (Staratton, I 973). The school was organized on a Study-hour System, in which the probationer nurses attend the classes and worked in the ward in. the same day. Also probationer nurses should be unmarried and remaìned single during their career Pre1imivarvTraining During the Japanese occupation between , nursing training was interrupted and suspended. The nursing schools reopened at the end of i 945. Hong Kong did not formulate a formal syllabus and curriculum for nurse training until the first qualified English sister tutor arrived in She modernized the training program by introducing the British concept of Preliminary Training to Hong Kong. During Preliminary Training, the probationer nurses enjoyed 3 months of full student status and learned basic
17 nursing and natural sciences prior to working ìn the wards (Lee, 1987). The training period was shortened from 4 years to 3 years Study-block System In the "Study-biockSystem" replaced the Study-hour System. Probationer nurses studied full-time for a total of 20 weeks, which were divided and spaced over the three years during the course of their training. In i 968, the ftill time study period was increased to 34 weeks. And the title of the trainee was changed to "student nurse". The clinical experience phase was planned, recorded and evaluated and students placed in different clinical areas. The student nurses were also regarded as a substantial part of nursing manpower in the hospital. Conflict between the needs of the service and the educational needs ofthe student was inevitable. The curriculum continued to be up-dated periodically to keep abreast of the medical advancement and development. The full time study period also gradually increased to 42 weeks. Hong Kong's nursìng schools have grown and multiplied, and nursing traìning is conducted in government, government-aided and private hospitals. English is used in the government hospitals, and Englìsh or Chinese is spoken during instruction in the other hospitals. The general nursing course was for a three-year period and consisted of theory, practìcal, and examination components. During the course, student nurses provided a o
18 high proportion of the dìrect patient care in hospitals and formed an important part of the workforce. There are two streams of RN training: general and psychiatric. Student nurses have to pass the Nursing Board Examination for registration before they can practice as a RN. There are at present I 3 nursing schools providing RN training. The Hong Kong health care system had been undergoing rapìd and unprecedented changes since The Hospital Authority (HA) is a statutory body established in i December 1990 with responsibilities ofmanaging all public hospitals in Hong Kong. The HA increased the study time of hospital based nursing school training from 42 weeks to 51 weeksinmay It can be concluded that the hospital-based apprenticeship system for training RNs is still the way of producing the majority of nurses for meeting the need of the health care system ìn Hong Kong. At present, there are about student nurse graduates each year from nursing schools Nursing Board of Hongjng The Nursing Board of Hong Kong Nursing (now renamed as the Nursing Council of Hong Kong), the statutory body for regulating the professional training and practice of nursing, was established in Nursing Board of Hong Kong (NBHK) is responsible V1
19 for supervision of the nursing educational institutions, monitoring the qimlity of nurse training and maintaining a register of practising nurses. The NBHKs register for trained nurses was dìvìded into general nursing, psychìatric nursing. and midwifery. In order to maintain nursing standards, ìt controls the nursing curriculum by stipulation requirements for entering nursing training, the content and length of time for theoretical instruction and practical training (Combes, 1984). The teaching became standardized and the admìnìstratìon ofthe nursing student was independent of the hospital (Lee, 1987). 2.3 Teaching Staff Not until the early sixties, did a few more locally trained Chinese nursing sisters receive their Sister Tutor's diploma in Scotland. However, political turmoil, including the riot of 1967, resulted In many tutors leaving Hong Kong and emigrating to Canada, the United States and Australia. The problem of shortage of tutorial staff became most acute by the end of i 967 because there were only four qualified tutors. The Australian ten-month Diploma in the Nursìng Education Course was selected to replace the British two-year Sister Tutor's Diploma course (Lee, i 987). Nurses were selected on an annual basìs and sent to the College ofnursing in Melbourne since As with Hong Kong, the system of education for the general nurse in Australia developed largely out of the Nightingale model, which was introduced into New South Wales in I 868 (Russell, i 990). Since the nursing educators were trained and educated in Australia, developments in the Australian 8
20 nursing education have had a great impact on Hong Kong's nursing education. The Nightingale model for the education of the general nurse has remained virtually unchanged for nearly loo years. Hong Kong Polytechnic is the first local tertiary institutìon to provide training of nurseteachers. It is a two years full tìme post registration certificate course. Most of the nurses studying in this course are selected and sponsored by the teaching hospitals to study. They were still the full pay staff of their hospitals. Therefore, the source of nurse teachers was very limìted and controlled by the employer. As nursing education in Hong Kong has progressed a great deal recently, all the nurse teachers are required to have a basic baehelor degree in nursing and are preferred to have a master degree. Hong Kong Polytechnic University provided a one and half year postgraduate nursing education program instead of two years full time certificate course. Tertiary education become very popular in nursing and more nurses received higher education in local and overseas universities. Nursing Board of Hong Kong also ìssues "Indicator of registration of nurse teacher" to nurses who hold a relevant masters degree which allows them to be employed as Nurse Educators (NE). As a result, there is more flexibility for nurses to enter the teaching profession.
21 3. The Nursing Education_System of Other Countries Hong Kong, likes other majority of developed countries, the demand for health care continues to grow as the population ages, and increasingly well-informed patients demand better care. Nursing education in Hong Kong has progressed a great deal since the turn of the century and the standards of practice are competitive with other countries. The current trend of UK nursìng education seems greatly influenced by Australia and United Kingdom (UK). Understanding the complex situation of nursing education of other countries, allow us a boarded scope of view about the advantages and disadvantages of different nursing education programs. Some of the assumptions HA make about the nursing education system may be challenged by the reality of the other advanced countries health care system. It is hoped that we can learn something for theìr experience 31 The Nursing Education System in United Kingdom The majority of general nurses in the United Kingdom were trained in hospital-based schools of nursing under an apprenticeship system. The training was patterned on the Nightingale model. In UK, the universities and colleges played a very significant role in developing nurse education, following the introduction of undergraduate and postgraduate degrees for entrants to nursing and for those already qualified in 1960s. The first of these courses began in i 956 at the Unìversity of Edinburgh and led to a normal lo
22 degree (BSc or BA) plus a qualification as a registered nurse (Rusell, 1990). Some of the hospita1based schools of nursing arranged cooperative links with universities and developed programs in which a nursing qualification was linked with a degree. A number of hospital-based schools offered courses linked with polytechnic schools, which prepared students for registration and the Diploma in Nursing. In times of war, the Nurse Acts 1943 allowed the 'enrolment of assistant nurses for the sick'. This allowed people who had had little or no training access to a form of recognition as 'trained nurses and which opened the door to second level nurse training (Chapman, I 998). Subsequent events have shown the problems of two standards and the abolition of Enrolled Nurses (EN) nursing education was contained withìn the Project 2000 proposal for a New Preparation for Practice (UKCC 1986). The Project 2000 places the emphasìs on 'education' instead of the tradìtion focus of 'train.ing. Project 2000 proposals recommend that nursing students should be supernumerary to manpower needs for the first I 8 months of a three-year course (Chapman, 1998). Project 200 diplomats only spend 20% oftheir course time in rostered clinical service, compared to 60% in the previous apprentice-style (traditional) courses (Elkan et al, 1993). It took 40 years for nursing in the UK to make a major move into higher education. The United Kingdom Central Council (UKCC, i 986) argued for the end of EN training, promoting a single grade RN qualification with a diploma. Ultimately, 11
23 this would end the split in the register where two grades of workers are called nurse', enhancing the status of the profession. The jobs of current ENs were safeguarded; they could either continue at the same level until retirement or upgrade to RN level. EN traìning subsequently phased out (Francis & Humphreys, 1998). The planned phasìng out of the EN role left a financial deficit in UK nursing care. In its Project 2000 proposals, the UKCC (1986) admitted that it would be unrealistic to assume that the new, more qualified Project 2000 nurse would carry out menial tasks. This would simply prove too costly and it resulted in a huge amount of debate In UK (Francìs & Humphreys, 1998). The Health Care Assistant (HCA) is usually qualified through national vocational qualification (NVQs). Although the period of training can be as short as sìx weeks, certain competencies and achievements must be reached. Although they comprise only small proportion of the healthcare workforce, the number of wholetime HCA equìvalents increased by 22 percent in the year in UK. Thus HCAs have increased in number by 1 per cent ofthe total workforce in one year, suggestìng that they have replaced a significant proportion of nurses. Thus raising concerns within the received the nursing profession and public concerns over the standard of patient care. 12
24 3.2 The Nursing_Education System in Australia The Australian professional nursing register is split between first (RN) and second level (EN) nurses. Also registered nurse education has followed a similar path form being hospìtal-based to higher educatìon during the past decade. RN trainìng moved from hospital to university and the shorted EN training began in most states. The past decade has been a tìme of significant and continuing change for nursing education in Australia (Thyer & Bazeley, 1 993). Nursing education has had a transition from hospital training to tertiary sector education. The last hospital nursing training intakes anywhere in Australia were to be in The first state to achieve the transfer of all basic nurse education into the tertiary sector was New South Wales in 7 November (Department of Community Service & Health, i 990). Unlike other courses within the tertiary sector, which were funded by the federal government. the new nursing programs in New South Wales were funded directly by the state government through the Ministry for Health. Subject to negotiation with the states and territories of satisfactory transitional arid cost sharing arrangements, the full transfer in the whole country of nurse educatìon into the tertiary sector was completed in As a result, hospital-based schools of nursing with long and proud histories ofover loo year ceased to cxìst (Robert, 1990). 13
25 4. Çurrent DeveIopment ofnursing Education in Hong Kong The past few years have been a time of significant and continuing change for nursing education in Hong Kong, wìth nursing education experiencing a transition from hospital training to tertiary sector education. The current condition in Hong Kong is very similar to Australian and UK nursing education in the i 960s and I 970s. At that time, the nursing profession in Australia passed through a period of industrial and professional turmoil. There were many conflicting opìnìons, both from within and outside the nursing profession, on the most appropriate way to educate nurses As a result, many modifications and changes to this model were introduced, leading ultimately to the transfer of all basic nurse education into the tertiary sector. In i 990, the Hong Kong Government gave approval for the universities to run the basic nursing degree programme. There were 40 places for the pre-registration degree programme, and the number of degree places in universities would be increased to i 80 in In 1992, The Hospital Authority (1992) claimed to support transferring basic nursing education to tertiary level. The 1992 report ofthe HA Working group on Nursing Education recommended that basic nursing education be upgraded to the level of a 4-year undergraduate baccalaureate degree. Moreover, a comprehensive-generalist program should be developed leading to single registration and that nurse education be transferred 14
26 in planned stages to the tertiary education sector. Nursing schools were encouraged to consider re-organizìng their programs in a way that student nurses may have a 'taste of tertiary. However, the turnover rate of nursing staff was high and nursing schools had difficulty in employing enough nursing staff. At that time, the reorganizatìon of nursing programs could not be allowed to upset the manpower supply in clinical areas. As a result, various types of programs emerged in nursing education in Hong Kong since early I 990s. Current pre-registratìon programs include the bachelor degree programs offered by tertiary institutions and various dìploma programs (e.g. Higher Diploma' and 'Professìonal Diploma' programs offered jointly by hospital nursing schools. A baccalaureate nursing programme has been introduced in the Hong Kong Polytechnic UnIversity since I 990, followed by The Chinese University of Hong Kong and the University of Hong Kong. However, compared to other modern countries, the development of Hong Kong' s nursing education is far behind. It may be due to the fact that the traditional 3 year hospìtal based nursing training programs not only provide education but also supply manpower to hospitals. The transformation of nursìng education involves different parties and authorities. The four major parties are Hospìtal Authority, hospitals, nursing schools and universities. 15
27 From the hospital and Hospìtal Authority's point of view, upgrading nursing training to tertiary education can promote the professional image of nursing, improve nursing care quality and decrease training costs. However, it loses a source ofcheap manpower supply. The hospitals need to ask for more funding to employ registered nurses to take over the job of nursing students thus it increasing the cost of health care services. The transition of nursing education needs a large amount of ftinding from the Hong Kong Government to both universities and hospìtal if the student nurses are replaced by same number of RNs. From the experience of Australìa, the transfer of nursing education into the tertiary sector had required funds of approximately $ AUD 50 million for tertiary institutions (Roberts, I 990). Since Hong Kong experienced an economic crisis recently, the government urged HA to cut 5% total budget for new service. According to the HA annual plan i 999/2000. productivity gains from resource management initiatives, equivalent to HK$224 million, will be deployed to shorten waiting time for specìalist clinìcs and new services. The concern of nursing education becomes one of how to use the available resources in the most efficient and effective manner in order to have the most robust impact on the condition at hind. Just shortly before the announcement of closing all nursing schools except one, the Hospital Authority urged the universities to provide a suitable curriculum, whìch could provide cheap man power to hospitals and minimize funding cost. Now, there are many dìfferent nursing programs existing and they vary from hospital to hospital and even from 16