The implementation process and its outcome as revealed in this study should not be taken as a reflection of the situation in all nursing schools in Hong Kong as this is a case study of one nursing school. However, the findings may shed some light on the work of curriculum developers and those concerned with nursing education in other nursing schools.7.2 Major Problems and Recommendations
From the present study, it is evident that despite the hard work and devotion of the staff in the case school, the level of implementation was low. Major problems associated with the implementation are:
Discussion about the major problems and recommendations for improvement will be presented in the following section.
- (a) discrepancy between the syllabus requirements and the Registration Examination demands;
(b) hospital context is not ready for the change; and
(c) absence of essential support.
A. Discrepancy Between the Syllabus Requirements and Registration Examination Demands
The discrepancy between the syllabus requirements and the Registration Examination demands has negative impact on teachers' commitment in adopting the recommended teaching approach. According to the syllabus, teachers are required to equip students with' critical thinking and problem solving skills necessary for the nursing process approach. However, analysis of the Hong Kong Nursing Board Registration Examinations reveals that the vast majority of the examination questions were set to test students' ability to recall knowledge while the intellectual skills required for the nursing process were not measured. Under the present training system, students have to pass the Hong Kong Nursing Board Registration Examination before they are eligible to register with the Nursing Board and become a qualified nurse. It is understandable that both teachers and students see passing the Nursing Board Examination as an important goal. So like secondary education they are led by the examination requirements. Unfortunately, the examination papers are content-oriented. This has discouraged nurse teachers from investing time and effort in developing students' critical thinking or problem-solving abilities. Being influenced by the nature and the format of the Registration Examination, teachers tended to direct their teaching towards instilling knowledge. The amount of instruction time available for them to cover the syllabus and to drill students became a very important issue. Teachers claimed that owing to insufficient instruction time, lecturing was unavoidable. The facilitative teaching approach and active learning encouraged in the new curriculum were perceived as time consuming and unworkable. In 1995, the Hospital Authority suggested a remedy by simply increasing the learning element for student nurses by 22% (additional nine weeks of theory input for general nurse curriculum). But this may not have significant results. In order to encourage teachers to implement the new teaching approach, it might be necessary to conduct a critical review of the nature and format of the Hong Kong Nursing Board Registration Examination to make it more compatible with the new curriculum.
As indicated by Morris (1992), within a highly centralized system which places a premium on education as a process of certification, the public examination can be used as a major tool for implementing curriculum change. He points out that,
The Hong Kong Nursing Board has endorsed the importance of the nursing process and individual nursing schools are required to equip students with the knowledge, skills and attitudes necessary for its practice. These requirements should be reflected in the Board Examination.
- " The change in the content and perspective was effectively implemented by changing the examination syllabus, the types of questions set and most importantly the nature of the marking schedule. "
(Morris, 1992, p.75)
B. Hospital Context is not Ready for the Change
This study has discovered that the curriculum innovation was introduced without the appropriate ground work being laid. As a result, hospitals are not yet ready for the exercise. The aim of the curriculum innovation is to improve the quality of nursing through an introduction of a new curriculum designed for developing student nurses' skills in the nursing process. The implementation of the innovation not only requires a change in the curriculum content but also a change in clinical practice from the traditional approach of care to the nursing process approach of care. However, findings of the study indicate that the hospital environment is not yet ready for this change. The nursing process approach of care promoted in the new curriculum is not being practised in the clinical setting. The nursing practice in the hospital is still disease-oriented, task-centred while the role of nurses and patients remains unchanged. Some practical strategies are recommended and presented in the following section to remedy the situation.
Based on an extensive study on the evaluation of the implementation of the nursing process in the United Kingdom, the Nursing Process Evaluation Working Group (1986) comments that successful implementation of the nursing process within a clinical or educational setting requires not only extensive ground work being laid in hospitals but also the cooperation of all those concerned: practitioners, nurse teachers, managers, doctors and other health care workers. The Working Group (1986) goes on to suggest that for the introduction to be successful, important decisions have to be taken by nurse teachers and practising nurses supported by their respective managers who must recognise that adoption of a different approach to nursing care imposes strains on a work force which may already be under pressure and can result in high stress levels for many of those concerned.
The World Health Organisation [WHO] (1991) stresses that nurse teachers alone cannot bring about the needed change in the schools. For effective implementation nurse teachers, nurse managers and clinical nurses should work together in a spirit of mutual support and understanding of the aims of the change. Shaw (1992) also points out that strong linkages between education and service is essential for the effective management of change. She said that,
In addition to obtaining the support of nursing colleagues, it is necessary to involve the medical staff prior to introducing the nursing process to avoid giving medical colleagues the impression that nurses have changed their patterns of work and approach to patients without informing the doctors. (Nursing Process Evaluation Working Group, 1986). The involvement of medical staff could help nurses to clarify misconceptions about the aims and the nature of the nursing process. Learning (1983) as quoted in the report of the Nursing Process Evaluation Working Group (1986), pointed out that,
- " Linkages between nursing education and nursing services must remain strong and effective at all time, but most particularly during times of significant and rapid change. If this does not happen, their educational preparation may be less realistic in terms of the environment that nurses will be working in, and change in these services may be harder for nurses to accept. "
(Shaw, 1992, p.54)
Apart from obtaining the support of nursing and medical colleagues, support from hospital administrators must also be secured prior to the process of change. The introduction of the nursing process requires considerable resource investment. In order to meet the development needs of the trainees appropriate staff development progranunes should be Provided and this is where the administrators' support is critical for they play a key role in obtaining and allocating resources. WHO (1991) stresses that,
- " At first it (the nursing process) seems similar to the medical process, but then you realise that it is different and that it is helpful, essential, to good interdisciplinary health care. "
(Learning, 1983 as quoted in the Nursing Process Evaluation Working Group, 1986, p. 16)
The application of the nursing process calls for a fundamental change in attitudes between patient and nurse. The patient becomes a partner in care and where possible is consulted at each stage of the process (Nursing Process Evaluation Working Group, 1986). This implies that patients (the public) need to be involved in the change process. The public need to be informed about the purpose and the nature of the nursing process and should be consulted about their opinions towards their participation in the caring process. Recently the Hospital Authority has launched a large campaign in promoting the Patient Charter, this may be a ground work for the promoting of the nursing process approach too. The aim of the Patient Charter are not only to promote the rights and responsibilities of patient but also encourage active involvement of patient in the health care services which is in line with the philosophy of the nursing process approach.
- " Administrative support is crucial to the change process and all efforts to achieve change are likely to be frustrated unless such support is forthcoming from informed and committed administrators. "
(WHO, 1991, p.20)
Clearly the many diverse efforts to introduce the nursing process must be collective and coordinated. Before embarking on the change support from nursing colleagues, the medical staff, hospital administrators and patients should be secured. Insufficient support from all parties or the absence of preparatory inter-professional dialogue and consultation will bring about discrepancy between theory and practice, the end result of which is teachers' frustration and disappointment with the teaching of the nursing process.
The process of curriculum development should also be reviewed. It might be helpful to make the curriculum development a joint venture among nurse teachers, nurse managers and hospital administrators. Medical staff, other health care workers and patients should also be involved at an early stage of planning and implementation.
C. Absence of Essential Support
Teachers hold the key to any process of educational change. To enhance teachers' competency in the new teaching approach which is an important element in the introduction of the nursing process, adequate educational preparation and continuous assistance must be made available to the teachers. These essential supports were found to be conspicuously absent in the case school. Teachers were not allowed adequate time to enable them to learn and plan for the new practice; there was also a lack of appropriate teaching and learning materials as well as continuous assistance and input of professional knowledge. These inadequacies could be one of the reasons for teachers' frustration leading to the unsatisfactory results of the implementation. A similar scenario was found in Lam's (1991) study on the development and implementation of moral education in Hong Kong. He commented that,
What might be done to enhance the level of change? How might curriculum developers and those involved in nursing education in Hong Kong achieve a better result? In view of the present situation in Hong Kong, several strategies may induce the desired change.
- " Though teachers were very committed and ready to make personal sacrifices for the curriculum change, lack of professional knowledge and experience seriously affected their effectiveness and the level of change achieved. If these teachers had been better equipped, the implementation process would have been much smoother and would have yielded better results. "
(Lam, 1991, p. 175)
- Staff Development
Mutual Support Among Nursing Schools
- As indicated by Fullan (1992), staff development is a strategy for effective implementation and a means to motivate teachers to adopt innovative programmes. Staff development can be conducted in many forms. Formal training can be offered during pre-service training. It can be in-service programmes offered by the Institute of Advanced Nursing Studies, Hospital Authority, college of nursing in Hong Kong, tertiary institutions and individual schools. According to Lam (1991) school-based staff development activities have several advantages over territory-wide ones, viz. the programmes can be tailor-made to meet the needs of individual teachers, practical advice can be channeled to those attending the course, and participants save on travelling time. Lam (1991) goes on to stress that no matter which form of staff development is adopted, the central agency should try to provide a certain amount of resources and support to the organisations and individual schools organising these staff development programs. Teachers must be given adequate time to learn, digest, think and reflect and develop their professionalism (Lieberman, 1992). The Nursing Process Evaluation Working Group (1986) also indicates that it is a fact of life that the implementation of change will almost always incur some costs - both direct and indirect. On the other hand, if change is effected successfully, it is reasonable to assume that some financial savings and/or great efficiency may result. Although the nursing process approach has been formally introduced recently in Hong Kong, there is little evidence of its success or failure. However, in the United Kingdom, some positive outcomes have been reported (Law, 1979/80) including
It is hoped that this will convince the statutory body, the Hospital Authority of Hong Kong of the importance of giving adequate resources to nurse teachers for staff development activities.
- - improved nurse-patient communication;
- improved the content of written records;
- continuity in patient care in hospital and between hospital and community;
- a framework for nurse education at basic and post basic level; and
- nursing workloads assessed by means of individualized patient care plans.
Collaboration Between Teachers
- There are only ten nursing schools in Hong Kong offering the three-year hospital-based certificate programme. It may be practicable and helpful to develop a network among the nursing schools to study and deal with issues related to development of the new curriculum and its implementation. This network concept implies collaboration in the use of resources, and the sharing of expertise to facilitate curriculum development. Those involved in the network would be able to learn from joint ventures, to improve existing programme, to develop new ones and to become increasingly self-reliant (WHO, 1991). Collaborative activities might include curriculum design, the preparation of teaching materials, the development of improved teaching approaches, practices and appropriate methods of assessment, and the sharing or exchange of learning facilities and resources, the identification of research topics and joint research ventures. Through a wide range of collaborative activities, teachers would become more confident in curriculum design, be more comfortable with new teaching approaches. The problem of the availability of teaching and learning materials could be resolved, as more local materials would be produced through the joint effort. The Nursing Process Evaluation Working Group (1986) also emphasizes the importance of stimulating a spirit of enquiry into methods of teaching and learning, and encouraging nurse teachers to work together more closely in devising and try out materials that might contribute to the improvement of nurse training.
Provision of Local Facilitators
- Teachers collegiality and collaborative work cultures are known to be related to the likelihood of implementation success (Fullan & Pomfret 1977). Little and Milbrey (1993) has also identified the importance of collegiality in implementing innovation. They stress that peer interaction is a major factor in promoting change because collegial interaction facilitates teachers to discuss, observe, analyse and study problems together.
An obstacles to the development of collaborative working relations among teachers has been a shortage of time for teachers to meet, share, help and discuss within the regular school day. Fullan (1992) suggests that if teachers are to make the most of opportunities to meet discuss, solve problems, and do research, then the school day will have to be structured to accommodate these activities to the extent that these activities are viewed as integral to providing quality schooling. Lieberman (1992) also stresses that in a school where teachers assume leadership in curriculum and instruction and reflective action replaces routine practice, the need for providing opportunities and time for disciplined inquiry into teaching and learning becomes crucial. In a school of nursing, nurse teachers have to contend with heavy workloads, in their busy work schedule, how and where to find time might be a problem. To solve this problem, a critical review of the timetable and the job of nurse teachers would help to identify solutions. The review may be helpful in offering some insight into reprioritizing and redesigning teachers' daily duties to find time for collaborative activities. School administrators also have an important role to play. It is the administrators' responsibility to obtain and allocate sufficient resources to alleviate teachers' heavy workload.
- It is evident from this study that nurse teachers on the whole lacking the knowledge of and experience in the facilitative approach to teaching. At the same time they are not familiar with the nursing process and have little experience in curriculum development. In view of this, providing 'local facilitators' for schools would be useful to the nurse teachers. The key responsibilities of local facilitators are to advise on the change process and to provide support and reassurance to curriculum users when necessary. Lam (1991) confirms that the presence of a facilitator who can assist with the implementation is helpful, especially during in initial attempts. However finding enough suitable local facilitators will not be easy. She or he must be well equipped with professional knowledge of the nursing process approach and must have experience and expertise in school-based development work. It is hoped that with more resources and training input, experienced nurse teachers can, without much difficulty serve as local facilitators.
There are several lessons that can be learned from the experience revealed in the study. Firstly the Hong Kong Nursing Board Registration Examination has very strong influence on the teaching and learning process. Therefore the registration examination can be used as a major tool to induce and facilitate curriculum change.
Secondly, to launch a curriculum innovation involving changes in the nursing practice, appropriate ground work has to be laid. Cooperation and support from all those concerned should be secured before embarking on the change effort.
Thirdly, the findings of the present study reveal that the curriculum innovation appear to be carried out on an ad hoc basis with inadequate preparatory work. Implementation without adequate planning has left the teachers insufficiently prepared and unable to cope with the demands of the implementation. Although teachers have an almost completely free hand in designing the curriculum content and choosing teaching strategies, they are handicapped by their lack of professional knowledge of the nursing process and school-based curriculum development. When interview the teachers expressed the view that adequate staff development, practical guidance and advice from people who have expertise and professional knowledge but who at the same time understand their situation, would be a great help towards better implementation.
Fourthly, the findings also reveal that the innovation was not adequately assisted or supported by the Hong Kong Nursing Board and the Hospital Authority. Although a school-based curriculum development strategy was adopted, it was the responsibility of these central agencies to provide guidance and the necessary resources to ensure a greater degree of success in the implementation.
Finally, the investigator was able to obtain in-depth information and data from multiple sources through the case study approach. Working from a holistic view of the implementation process, the investigator was able to identify the problem areas and to investigate their causes. From this data, the investigator gained insight into the future directions of the innovation and was able to suggest certain measures for future improvement. Initially the dual role of the investigator who was also the principal of the nursing school of the case study was a barrier to gaining the trust of the teachers, maintaining confidentiality and protecting individual privacy. However, with caution and careful planning these problems were eventually overcome.
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