Are there any differences in attitudes of nurses and physicians towards nursing education?

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1 ORIGINAL ARTICLE Are there any differences in attitudes of nurses and physicians towards nursing education? Nino Hasanica 1, Lejla Ibrahimagić-Šeper 2, Larisa Gavran 2, Senad Huseinagić 1, Edin Selimović 2 1 Public Health Institute of Zenica-Doboj Canton, 2 Primary Health Care Zenica; Zenica, Bosnia and Herzegovina Corresponding author: Nino Hasanica Public Health Institute of Zenica-Doboj Canton Fra Ivana Jukića 2, Zenica, Bosnia and Herzegovina Phone: ; fax.: ; nino_hasanica@hotmail.com Original submission: 11 May 2013; Revised submission: 24 June 2013; Accepted: 22 August ABSTRACT Aim To investigate the attitudes of nurses, physicians, nursing postgraduate students, patients towards the method and level of nursing education in the Zenica-Doboj Canton, Bosnia and Herzegovina. Methods Descriptive analytical study was conducted among nurses and physicians employed in three public health institutions, as well as among students of nursing master study and among the in-patients and outpatients. An anonymous questionnaire was designed for the research. Block random sampling method was used, and subjects were divided into four groups: nurses, physicians, patients, nursing postgraduate students. Respondents were selected by simple random sampling. The study included 180 subjects, 50 of each nurses, physicians, patients, and 30 nursing postgraduate students. Results There were 67 (37.2%) males; 76 (42.2%) respondents were from the age group years. Only 21 (42%) patients had heard about the process of health care (p=0.005), and only 34 (64%) of them had heard about the nursing university education (p=0.005). In the group of physicians, 27 (54%) respondents found that knowledge was not required for nurses (p=0.90). Differences in attitudes between the groups were statistically significant relating to the progress of nurses to highest education level, e.g. Master s and PhD (p=0.01), and allowing nurses to manage nursing education (p=0.005). Conclusion In contrary to the physicians and patients opinion, nurse postgraduate students declared they were competent to manage university education and progress to highest education and scientific level. A compromise between nursing competence and responsibility in multidisciplinary teams, where the nurse should be an equal member, needs to be reached. Key words: health care workers, nursing skills, nursing research, university education. SEEHSJ 2013; 3(2):

2 South Eastern Europe Health Sciences Journal (SEEHSJ), Volume 3, Number 2, November 2013 INTRODUCTION Nursing is a profession in health care focused on providing health care to individuals, families and communities, so that they can achieve, maintain or restore optimal health and quality of life, from conception to death (1,2). Health care is a scientific field of knowledge based on the contribution of scientific workers in the field of nursing and evidence-based practice (3-6). In the world there are different forms of organizing nursing education (6-9). Training for the nurse in the U.S. can result in Diploma in Nursing in hospitals (6), Associate Degree in Nursing at the College (6), and Bachelor of Science in Nursing at the University (6), as well as a PhD or Doctor of Nursing Practice engaged in the research, improving nursing and health care in general, and in nursing education (6). In Canada, nurses must have a Bachelor degree (6). In Japan, the first university study program for nurses was opened in 1952, and since then it has been possible to obtain a Bachelor degree (7). In the UK, nurses must have a minimum degree of Master of Science in Nursing or a doctoral degree (1,6). In Croatia, the implementation of Article 31 of Directive 2005/36/EC of the EU for the education of nurses responsible for general care are currently being carried out (1,8). In Croatia, lower education for nurses includes medical high school, which lasts for five years integrally, of which the first two years are for the general education, and the next three are dedicated to nursing education; university level of nurse education in Croatia involves a three-year study (1,8). The EU s focus is directed to the Directive 2005/36/EC, which entered into force on 20 October 2007 (9-14). Its implementation should provide conditions for validation and recognition of diplomas in the field of nursing and midwifery in all member states and future member states (11-14). Article 31 of the Directive considers education in the field of general nursing (12-14). The person who begins training to be a nurse or midwife must first have completed ten years of general education (11-14). Education for the nurse or midwife must last at least three years, or a total of 4600 hours of theoretical and practical training at higher education institutions (11-14). Lectures should be represented by at least one third of the total number of teaching hours (11-14), and the practical part by at least half of teaching hours (11-14). Teachers should be a nurse or, possibly, other competent persons (11-14). In Bosnia and Herzegovina (B&H), according to the Law on Nursing and Midwifery of the Federal Ministry of Health, nurses and midwives can acquire basic education at high schools and higher education at universities (15). A positive example of the reasons for the establishment of a high level education for nurses was given by the Working Group for the assessment of needs for health personnel established by the Croatian Community of Faculties of Health in 1989 (1). According to this Group, the need for the production of own personnel and the need for further education of students with a high grade point average during the study, requires the establishment of a university level of education (1). This is the first study on the attitudes of health workers towards nursing university education in B&H. This research will provide information on nursing reform acceptance and will evaluate the relationship among health care workers. EXAMINEES AND METHODS This prospective descriptive-analytical study was conducted in the period May to July 2012 at the Primary Health Care Zenica, Cantonal Hospital Zenica, Public Health Institute of Zenica Doboj Canton, and Faculty of Health, University of Zenica. The adult intellectually capable participants of both sexes aged 18 and over, all citizens of Bosnia and Herzegovina were included. Block random sampling was used. Before the research, the subjects were divided into four groups: nurses, physicians, nursing postgraduate students, and the patients. Sampling was based on probability, so the sample was representative for the population. The study included a total of 180 respondents. The questionnaire designed for the study contained 10 questions. Three questions were related to the demographic characteristics of the 170

3 Hasanica et al Higher nursing education sample: gender, age, level of education. Five questions were related to attitudes regarding nursing education (Table 1, 2). The questionnaire had passed all stages of questionnaire testing on a group of 10 test subjects in order to check comprehension of questions. Nurses, physicians and nursing postgraduate students answered the questionnaire independently. Suggestive answers by interviewers was avoided in this way. Oral interviews with patients were performed in order to obtain the most reliable answers. The questionnaire was anonymous. Respondents answered the questionnaire only after obtaining their oral voluntary informed consent. Written consent was not used because of questionable anonymity. The Ethics Committee of the Primary Health Care Zenica, the Cantonal Hospital Zenica, and the Public Health Institute of Zenica Doboj Canton gave approvals for the performance of the research. Methods of descriptive statistics and chi-square test (χ2) were used for statistical analysis of data. The level of significance was p=0.05. RESULTS Of the total number of 180 respondents, 50 of each nurses, physicians and patients, and 30 nursing postgraduate students, 67 (37.2%) were males and 113 (62.8%) females. Most of the respondents were from the age group years, 76 (42.2%) respondents. All respondents from the group of physicians and Table 2. Attitudes of respondents on nursing education Question I find that skills are enough for nurses, and knowledge is not required. I find that progress to the highest education level, Master s and PhD, should be allowed to nurses. I would allow nurses to manage nursing education themselves, with minimal involvement of other fields of health care workers in the teaching process. N, nurses; Ph, physicians; NPS, nursing postgraduate students; P, patients Table 1. Knowledge of respondents on nursing education No (%) of respondents N Ph NPS P Have you heard about the terms: process of health care, nursing anamnesis, nursing diagnosis, nursing intervention, nursing evaluation? Have you heard about the university education of nurses at the faculties of health? 50 (100) 49 (98) 45 (90) 49 (98) 30 (100) 30 (100) 21 (42) 32 (64) N, nurses; Ph, physicians; NPS, nursing postgraduate students; P, patients nursing postgraduate students had completed university education, 94 (52.2%) of all respondents (data not shown). According to the group analyzed, 50 (100%) nurses, 45 (90%) physicians and 30 (100%) nursing postgraduate students and 21 (42%) patients were heard about some of the terms, e.g. the process of health care, nursing anamnesis, nursing diagnosis, nursing intervention, nursing evaluation (p<0.05). Forty nine each (98%) nurses and physicians, 30 (100%) nursing postgraduate students and 32 (64.0%) patients were heard about the university education of nurses at the faculties of health (p<0.05). Twenty eight (56%) nurses, 27 (54%) physicians, 19 (63.3%) nursing postgraduate students and 16 (32%) patients expressed very positive attitudes towar- Answers No (%) of respondents N Ph NPS P Totally disagree 28 (56) 27 (54) 19 (63.3) 16 (32) Disagree 19 (38) 22 (44) 11 (36.7) 32 (64) Undecided 2 (4) Agree 1 (2) (4) Totally agree 0 1 (2) 0 0 Totally disagree 0 2 (4) 0 0 Disagree 1 (2) 2 (4) 0 3 (6) Undecided 8 (16) 9 (18) 0 18 (36) Agree 24 (48) 21 (42) 8 (26.7) 14 (28) Totally agree 17 (34) 16 (32) 22 (73.3) 15 (30) Totally disagree 8 (16) 8 (16) 0 0 Disagree 15 (30) 23 (46) 7 (23.3) 15 (30) Undecided 9 (18) 8 (16) 1 (3.3) 24 (48) Agree 11 (22) 6 (12) 9 (30) 6 (12) Totally agree 7 (14) 5 (10) 13 (43.3) 5 (10) p

4 South Eastern Europe Health Sciences Journal (SEEHSJ), Volume 3, Number 2, November 2013 ds the need for the improvement of nursing knowledge, besides the skills acquired through practice (p>0.05). When discussing about the progress of nurses to the higher education level, e.g. Master s and PhD, 13 (26%) physicians expressed negative attitude, as opposed to 41 (82%) nurses, 30 (100%) nursing postgraduate students and 29 (58%) patients who expressed positive attitudes (p<0.05). The statement that only nurses rather than other health care workers can be involved in teaching of nurses was supported by 19 (36%) nurses, 22 (73.3%) nursing postgraduate students and 11 (22%) physicians (p<0.05). A total number of 46 (92%) physicians believed that the progress of nursing does not threaten other members of the healthcare team, while four (8%) of them were undecided; 27 (90%) nursing postgraduate students intend to work in the nursing field in the future, while three (10%) of them were undecided. DISCUSSION According to WHO proposal for European region, the governments of all European countries were invited to improve nursing and midwifery through the promotion of basic and more accessible university education for nurses and midwives, and it was recommended to establish the legal framework and all the necessary legislation in this area (15-18). In this study, there were 37.2% males, while in other studies the number of males dealing with health care and nursing is between 10.6% and 14.0% (19-22). There were 40.0% male nursing postgraduate students in this study, and in some other studies, the number of male nursing postgraduate students is much lower, about 14.0% (21). The majority of patients in this study, (52.2%) had university education. However, it should be noted that all respondents had university education, e.g. physicians and nursing postgraduate students. In other studies, the percentage of nurses with medical high school ranges between 69.4% and 94.6% (19-22). The employment services in Bosnia and Herzegovina have a large number of nurses with medical high school, even 90.0% to 99.1% (19). It turned out that there was a statistically significant difference between the groups of subjects when it comes to knowledge of the process of health care, nursing anamnesis, nursing diagnosis, nursing intervention, nursing evaluation. The question arises why patients largely did not hear about the basic concept in the nursing health care. Nurses are less engaged in their work assignments because they are preoccupied with administrative tasks (23). In EU countries, the USA and Canada, patients are heard about the main nurses work assignment process of health care (24). A small number of patients heard about university education of nurses, which indicates that there is not enough promotion of faculties of health (25). In the EU, the USA and Canada the number of faculties of health has progressed, and these faculties represent one of the most perspective ones (6,26). Nurses and nursing students in 94.0% of cases believe they can and should progress to the highest education level (8,19,23). Students of the master study should be teaching staff at faculties of health in the future (8,19). Of course, as it is the case with other professions, physicians should continue to teach subjects close to the medicine (8,19). A prevalence of 89.5% nurses and nursing students claiming that advanced nursing education does not represent a threat for other members of the healthcare team was noted in some research (27). Also, 100% of students claim that life-long learning is very important in nursing (8), and 94% that studies in nursing are important for the improvement of the profession and the functioning of the entire health system (8,20). It is encouraging that most nursing students from this study (90%) were intended to work in the nursing profession, which is similar to other research (95%) (28). Required changes in the process of nursing education include university education of nurses upon completion of high schools, and to establish a nursing specialization at the university level of education (29). Competence and authority of nurses with university education include participation in the planning and or- 172

5 Hasanica et al Higher nursing education ganization of health care, research in the field of health care, lifelong self-education in the field of health care (29). Moreover, a nurse can achieve the level of Master s and PhD in the field of health care and nursing (15,20). Nursing education models from developed countries, with a modern viewpoint, will be followed in Bosnia and Herzegovina, and in neighboring countries too (29). Nurses and nursing students, especially nursing postgraduate students, should be engaged in public debate about the law regulations pertaining to nurses. Improving the nursing position in the society of Bosnia and Herzegovina and countries in the region is privilege and responsibility. In this regard, nursing students should seek advancement to the highest education level Master s and PhD, and subsequent opening of new opportunities in employment in managerial and leadership positions in health and legislative institutions (13,18). Only in this way will the entry of nurses into the teaching process at faculties of health and the production of the own personnel be possible (18). It is necessary for nurses to engage in teaching in high schools (18). The status of university educated nurses is still quite often unresolved and undifferentiated. A compromise between nursing competences and responsibility in multidisciplinary health teams, where the nurse should be an equal member, needs to be reached. FUNDING No specific funding was received for this study. TRANSPARENCY DECLARATION Competing interests: None to declare. REFERENCES 1. Čukljek S. Fundamentals of health care. Zagreb: Health University, Ranković-Vasiljević R. Methods of teaching health care. Belgrade: Higher Medical School Belgrade, Dickson VV, Wright F. Nursing theorists and their work (7th ed.) by M.R. Alligood and A.M. Tomey (Eds.) (Maryland Heights, MO: Mosby Elsevier, 2010). Nurs Sci Q 2012; 25: Smith JM. Nursing theorists and their work (7th ed.) by M.R. Alligood and A.M. Tomey (Eds.) (Maryland Heights, MO: Mosby Elsevier, 2010). Nurs Sci Q 2012; 25: Baumann SL. Making a meaningful contribution to nursing theory. Nurs Sci Q 2012; 25: Mailloux CG. Using the essentials of baccalaureate education for professional nursing practice (2008) as a framework for curriculum revision. J Prof Nurs 2011; 27: Nolan MT, Huaping L, Zheng L, Chongmei L, Hill MN. International doctoral education partnership: the first full-time doctoral program for nurses in China. J of Prof Nurs 2011; 27: Tsoucalas G, Kousoulis AA, Karamanou M, Tsoucalas I, Androutsos G. The first official schools for nursing education in Greece: over a century of tradition. Vesalius 2011; 17: Paulson LV. A 75-year history of nursing education in North Dakota Prairie Rose 2012; 81: Čukljek S, Karačić J, Ilić B. Attitudes of students of third year of nursing study about the nursing in Croatia today. (22 April 2013). 11. Keighley T. European Union Standards for Nursing and Midwifery: Information for Accession Countries. Geneva: World Health Organization, Regional Office for Europe, data/ assets/pdf_file/0005/102200/e92852.pdf (15 August 2013). 12. European Commission. Proposal for a Directive of the European Parliament and of the Council amending Directive 2005/36/EC on the recognition of professional qualifications and Regulation on administrative cooperation through the Internal Market Information System. Brussels: European Commission, ec.europa.eu/internal_market/qualifications/docs/ policy_developments/modernising/com2011_883_ en.pdf (15 August 2013). 13. World Health Organization. Nurses and Midwives for Health WHO European Strategy for Nursing and Midwifery Education: Guidelines for Member States on the Implementation of the Strategy. Copenhagen: World Health Organization, euro.who.int/ data/assets/pdf_file/0005/125744/ E72918.pdf (15 August 2013). 14. The European Federation of Nurses Associations, The European Nursing Student Association, European Specialist Nurses Organizations, The International Council of Nurses. Position Paper on Synergy Between Directive 36, Bologna and European qualifications framework. Brussels, Geneva: efnweb.be/wp-content/uploads/2011/11/efn_position_statement_synergymrpq-bologna-eqf_en_final pdf (15 August 2013). 15. Federal Ministry of Health. Law on Nursing and Midwifery. Sarajevo. Federal Ministry of Health, 173

6 South Eastern Europe Health Sciences Journal (SEEHSJ), Volume 3, Number 2, November pdf (15 August 2013). 16. Federal Ministry of Health. Strategic Plan for Health Development in FBiH in Period Sarajevo: Federal Ministry of Health, gov.ba/images/federalno_ministarstvo_zdravstva/ zakoni_i_strategije/strategije_i_politike/dokumenti/ usvojeni_strateski_plan_1_.pdf (15 August 2013). 17. Christine L. Latham, Karen Ringl, Mikel Hogan. Professionalization and retention outcomes of a university-service mentoring program partnership. J Prof Nurs 2011; 27: Hasanica N. The study of knowledge, attitudes and behavior of health professionals and patients in relation to nursing as a profession. University of Zenica, Zenica, B&H, 2012; Master s thesis. 19. Milisen K, De Busser T, Kayaert A, Abraham I, De Casterlé BD. The evolving professional nursing self-image of students in baccalaureate programs: a cross-sectional survey. Int J Nurs Stud 2010; 47: Morberg S, Lagerström M, Dellve L. The perceived perceptions of head school nurses in developing school nursing roles within schools. J Nurs Manag 2009; 17: Safadi RR, Saleh MY, Nassar OS, Amre HM, Froelicher ES. Nursing students perceptions of nursing: a descriptive study of four cohorts. Int Nurs Rev 2011; 58: Fawcett J. Thoughts about evidence-based nursing practice. Nurs Sci Q 2012; 25: Tepina J, Skela Savič B. Aquired competences in the time of study nursing care at College of Nursing Jesenice aspect of technical medical interventions. In: Proceedings of the Third student conference in health sciences: Developing of interproffesional cooperation in education in the field of health sciences, Maribor, Slovenia, 15 September 2011, p Faculty of Health Sciences, University of Maribor, Maribor, Slovenia. 24. Jelenovec S, Železnik D. Activities and competences of the paramedic graduated health care worker a health care challenge. In: Proceedings of the Third student conference in health sciences: Developing of interproffesional cooperation in education in the field of health sciences, Maribor, Slovenia, 15 September 2011, p Faculty of Health Sciences, University of Maribor, Maribor, Slovenia. 25. Skela Savić B. Reasons for promoting further education in nursing under the Bologna process: a case of Slovenia. In: Proceedings of the 2009 EMUNI conference on higher education and research: Internationalisation and the role of university networks, Portorož, Slovenia, September 2009, p EMUNI higher education and research, Portorož, Slovenia. 26. Skela Savič B. Nursing care and research: some factors influencing the development of nursing as a scientific discipline in Slovenia. Obzor Zdr N 2009; 43: Segrott J, McIvor M, Green B. Challenges and strategies in developing nursing research capacity: a review of the literature. Int J Nurs Stud 2006; 43: Hoffart N, Waddell A, Young MB. A model of new nurse transition. J Prof Nurs 2011; 27: Ibrahimagić-Šeper L, ed. Historical overview of medicine and nursing. Zenica: Faculty of Health, University of Zenica, Zenica (B&H),

7 Hasanica et al Higher nursing education Postoje li razlike u stavovima medicinskih sestara i ljekara u vezi sa sestrinskim obrazovanjem? Nino Hasanica 1, Lejla Ibrahimagić-Šeper 2, Larisa Gavran 2, Senad Huseinagić 1, Edin Selimović 2 1 Zavod za javno zdravstvo Zeničko-dobojskog kantona, 2 Dom zdravlja Zenica; Zenica, Bosna i Hercegovina SAŽETAK Cilj: Utvrditi stavove medicinskih sestara, ljekara, studenata master studija sestrinstva i pacijenata o načinu i nivou obrazovanja u sestrinstvu u Zeničko-dobojskom kantonu. Metode: Deskriptivna analitička studija je provedena među medicinskim sestrama i ljekarima zaposlenim u tri javne zdravstvene ustanove, među studentima master studija sestrinstva te bolničkim i vanbolničkim pacijentima. Za istraživanje je bio formiran anonimni anketni upitnik. Korištena je metoda skupovnog slučajnog uzorkovanja te su ispitanici podijeljeni u četiri grupe: medicinske sestre, ljekare, studente master studija sestrinstva i pacijente. Ispitanici su odabrani metodom jednostavnog slučajnog uzorkovanja. Istraživanje je obuhvatilo 180 ispitanika, po 50 ispitanika iz grupa medicinskih sestara, ljekara i pacijenata te 30 studenata master studija sestrinstva. Rezultati: Od 180 ispitanika, 67 (37,2%) su bili muškarci; najviše ispitanika je bilo u dobnoj skupini od 41 do 60 godina- 76 (42,2%). Samo 21 (42%) pacijenata su čuli za proces zdravstvene njege (p=0,005), a tek 34 (64%) njih je čulo za univerzitetsko obrazovanje medicinskih sestara (p=0.005). U grupi ljekara, 27 (54%) ispitanika smatra da medicinskim sestrama nije potrebno znanje (p=0.90). Razlike u stavovima između grupa su bile statistički značajne s obzirom na obrazovanje medicinskih sestara u zvanje magistara i doktora nauka (p=0,01) i dopuštanje medicinskim sestrama da upravljaju sestrinskim obrazovanjem (p=0.005). Zaključak: Suprotno mišljenju ljekara i pacijenata, magistranti sestrinstva smatraju da su kompetentni da upravljaju univerzitetskim obrazovanjem i da napreduju do najviših obrazovnih i naučnih nivoa. Treba postići kompromis između sestrinskih kompetencija i odgovornosti unutar multidisciplinarnog zdravstvenog tima, gdje sestra treba biti ravnopravan član. Ključne riječi: zdravstveni radnici, sestrinske vještine, sestrinsko istraživanje, univerzitetsko obrazovanje 175