Chapter Two
Literature Review
This section gives the comprehensive review of recent literature related to barriers to HE in nursing. This chapter begins with search strategy used to retrieve the available literature about barriers to HE in nursing. It highlights the need and importance of HE in nursing. It provides review of global literature on barriers to HE in nursing and associated factors. Moreover, it also presents the gap analysis on the basis of current review of available literature.
Search Strategy
A systemic search was carried out through the use of different online databases. These included CINAHL Plus, Science Direct, Google Scholar, and PubMed. The search engines were directed to limit the search from the year 2005 to 2015. Other limits included only full text articles published in English language. Key words used for the literature search included barriers to higher education and nursing, challenges to higher education in nursing, deterrents to higher education and nursing, importance of higher education and nursing, and higher education in nursing. A large number of articles were found however, most of the articles were discarded after reading the title and scanning the abstract. Initially, 54 articles were considered for the current study on the basis of relevancy of the title, abstract, and context of the study.
Importance of Higher Education
HE in nursing has been found very effective for improving critical thinking, problem-solving skills in nurses which ultimately result in better patients’ outcome (Rosseter, 2014). Healthcare setups where majority of nurses have at least bachelor level of education, have been found to have lower level of mortality and morbidity rate as compared to employers which have diploma prepared nurses (Friese, Lake, Aiken, Silber, & Sochalski, 2008). Similarly, a study conducted in Pennsylvania reported that 10% increase in the proportion of BSN nurses was directly associated with 2. 12 times decrease in long term mortality of surgical patients (Kutney-Lee, Sloane, & Aiken, 2013). Likewise, findings of a large survey identified that, more than 75% of the physicians acknowledged the competencies of nurses holding BSN degree compared to those with associate degree (Melichar, 2014).
According to a study byDrennan (2008)conducted on 322 MSN graduates in Ireland identified that, Master prepared nurses in practice resulted in better outcome of patient’s care because of advance level of knowledge, critical thinking, problem-solving, and managerial skills. Similarly, Watson (2006)asserted that higher education plays an important role in preparing nurses for competent and skillful care of the growing and challenging needs of modern healthcare industry.
Barriers to Higher Education in Nursing
According to a report by Institute of Medicine, highlighted that, nursing education in the US needs major transformation to meet the challenges of modern healthcare industry (IOM, 2011). Moreover, it has been suggested that a great proportion of nurses to enter the nursing practice should be baccalaureate prepared or should progress to degree programs at an early stage of their carriers.
However, there are certain barriers due to which nurses cannot attain HE. In a longitudinal US representative study of 1648 nurses, the participant reported that financial constraints, lack of time, lack of interest in a higher degree, satisfaction with current job, lack of local programs are the main challenges to HE (Kovner, Brewer, Katigbak, Djukic, & Fatehi, 2012). Another study conducted on barriers to HE in nursing in Louisiana, USA reported, lack of financial resources, family responsibilities, lack of flexible schedule and increasing age act as a major barriers in pursuing HE (Broussard & White, 2014).
Also nursing profession in the United Kingdom is facing challenge of being under the influence of National Health Service (NHS). Consequently, the NHS has authority over the curriculum and hence is a hindrance in development of the profession. It is further reported that nursing profession in the UK needs to be developed independently to show its contribution to the healthcare industry (Chambers, Porock, & Aston, 2010). Similarly, a recent report byTaylor, Irvine, Bradbury-Jones, and McKenna (2010)claimed that higher education’s funding for nurses and allied health professionals is not as transparent and sustainable as for the field medicine and, the competence and flexibility of nursing workforce is not similar across the UK. Sturgeon (2012)argued that introducing alternative degree awarding institutes and making competition among higher education institutes with support for flexible programs and distance learning will decrease the barriers to further education for healthcare providers in UK. He stressed that providing financial powers to students, adequate information before enrollment and quality education and academic transparency is important to increase enrollment.
A Swedish study on perception of Registered Nurses (RN) regarding their work environment and opportunities of professional education indicated that the RNs require a motivating work atmosphere and institutional support for professional development in terms of HE in their carriers (Danielson & Berntsson, 2007).
According to a qualitative study conducted in South Africa to explore the barriers to HE in nursing (Essa, 2011) on those who were unable to complete their MSN program. the results showed that workplace responsibilities, inadequate program information, inadequate skills for advanced studies, unexpected circumstances, feelings of disappointment, failure and regret, students attitude towards their study, and administrative shortcomings were the main reasons which led to the drop out of the participants. A cross-sectional study was conducted in Ethiopia to explore the determinants and opportunities for advanced education among healthcare professionals. The results showed that majority of the participants were willing to participate in advance education. However, 71. 8% reported lack of support from employers, 42. 3% reported lack of funding and 9. 4% mentioned other resources as main reasons for them not to participate in higher education (Fentahun & Molla, 2012). A similar study design was used byBell, Rominski, Bam, Donkor, and Lori (2013)to describe the strength, challenges and current status of baccalaureate nursing education in Ghana. The findings showed that, severe shortage of nurses, qualified nursing faculty and substandard infrastructure are the challenges faced by baccalaureate nursing education in the country.
Similarly, few Asian studies have also explored the barriers to HE in nursing. According to a Pilipino study conducted to explore the challenges faced by the nursing education of the country. The important emerged themes from the in-depth interviews revealed that, propagated culture of nurses’ migration, misuse of scarce resources, corruption in the nursing education, and disparity in healthcare personnel are the main challenges faced by the nursing education sector of the country (Masselink & Lee, 2010). According to a study byCleary, Horsfall, Muthulakshmi, Happell, and Hunt (2013)on graduate nursing students in Singapore identified that insufficient support from workplace, few carrier development chances, shortage of nursing working force, and lack of fair access to higher education are the main constraints for professional development. According toTurale, Ito, and Nakao (2008)control of nursing curriculum by the central health ministry, lack of well-prepared faculty, lack of innovative practices, lack of updated syllabus, and lack of international collaboration are important challenges faced in nursing education in Japan.
Beside western literature and research from other parts of the world, there are some studies from Indian subcontinent, which have addressed the phenomenon as well. Recent studies from India have reported that major barriers faced by nurses and nursing educators in the country are theory practice gap, lack of qualified and confident teachers, lack of teaching materials, little emphasize on research, and non-uniform syllabi (George, Roach, & Andrade, 2011). Similarly, Kharde (2012)reported that current challenges in nursing education in India include inadequate plan for development of nursing, limited participation of nurses at policy level, ineffective leadership and strategic management, limited production of academic and research work, and lack of system for continuous professional education.
In Pakistan nursing education is still in early stages of development. Only 33% of the nursing workforce in Pakistan has BSN degree (Manzoor et al., 2010). There is an acute demand of BSN and MSN prepared nurses to fulfill the requirement of the growing population and challenging healthcare system (Meghani & Sajwani, 2013). Cross-sectional studies conducted in Islamabad to determine the level of job satisfaction among nurses and other healthcare professionals working in public sector hospitals in Pakistan. The results showed that lack of professional development opportunities was one of the major reasons of dissatisfaction among the participants (Bahalkani et al., 2011; Kumar, Ahmed, Shaikh, Hafeez, & Hafeez, 2013)
(Mustafa (2005)) conducted a study to describe the major barriers to HE in nursing in Sindh, Pakistan. Data were collected from eight out of 29 hospitals of the province including both public and private sector hospitals. The dependent variables of the study included organizational barriers, educational and schooling barriers, and political barriers. Among the 159 participants 92. 5% were female and 7. 2% were male, having age 35±9 years. Majority of the participants (61%) were Christians and remaining (39%) were Muslims; 62. 3% of the respondents were married; having children 80. 8%; having nuclear family 58%; and belonged to urban setting 78. 6%. Ethnically, 73% were Punjabi, 11. 3% were Muhajir, and 9. 4% were Pathan. A majority of the participants 79. 2% were working on the post of charge nurse and remaining were on managerial or teaching posts. Among the participants, 68. 8% were employed in public sector and the rest were working in semi-private or private hospitals. The findings showed that among the respondents 92. 2% reported organizational barriers, 89. 4% reported cultural barriers, 82% reported educational and schooling barriers, and 79. 89% reported political barriers. This is an unpublished study, conducted in Sindh province of the country.
Gap Analysis
In the light of the above literature review, it can be concluded that in recent years, there has been considerable interest to study challenges and barriers to HE in nursing around the world. Identified barriers and challenges are contextual based and vary from country to country. Pakistan is a resource constraint country, having shortage of nursing workforce and limited educational opportunities for nurses. However, it seems that little importance has been given to identify the barriers to HE in the country, particularly in KP which is an underprivileged province in terms of research and development. According to the best of the researcher’s knowledge, there is no specific published study in Pakistan on the topic of barriers to HE in nursing. It is therefore needed to study the barriers to HE in the province of KP.
Summary
Globally, HE in nursing has been reported to be effective in providing skillful nursing workforce and improving patients’ care and health-related outcomes as result of evidence based nursing practices. Different reputed organizations have continuously highlighted the growing importance and need of HE in nursing. However, there are certain barriers and challenges which hinder the nurses to pursue higher education. Among the reported barriers, financial constraints, lack of support from employers, family responsibilities, lack of resources, and lack qualified faculty are common. Therefore, this study aimed to explore and study the barriers to HE which are important and relevant according to local context and to further suggest effective strategies and recommendations to overcome these barriers.
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