The purpose of this study was to explore the experience of nurses attending formal education while actively working.
MethodThe study used a qualitative method with a phenomenology approach. The participants consisted of 15 nurses attending formal education (Bachelor of Nursing, Nursing Professional designation, Master of Nursing, and Nursing Specialist) while actively working in one general hospital in Jakarta, Indonesia. Participants were selected using the purposive sampling technique. The data were collected with in-depth interviews and analyzed using Colaizzi's method.
ResultsFour main themes from this study emerged, including (1) becoming a professional nurse, (2) self-funding for school costs, (3) feeling guilty about nursing assignments, and (4) lack of rest time.
ConclusionsThis study concludes that nurses are attending formal education while actively working face various challenges and also have an impact on the safety of nurses and patients.
Formal education is highly important to the nursing profession. Nurses are obligated to engage in continuous education throughout all career stages based on job demands and legal requirements.1,2 Nurses also work in complex health care systems to meet patients’ needs, as well as the needs of current and future public health services.3,4 This has necessitated nurses to continue to develop the best nursing service practices and to engage in lifelong learning.5
Lifelong learning through continuing education in the nursing profession is a priority for several countries. Continuing education is a problem with the fifth-highest rating, requiring further attention.6 In some countries, continuing education is now mandatory and a requirement to maintain professional status, so the demand by health care organizations on nurses to continue formal learning tends to increase.7 For example, low-resource countries, such as Latin America and Sub-Saharan Africa, have identified further education as a critical field in the nursing development agenda and as an approach to strengthening the nursing profession.8
Continuous education is not only a priority for countries, but it is also regulated. Participation in continuing education in several countries is required legislatively.9 In addition, 23 states in the United States have enacted laws requiring nurses to participate in continuing education, with the aim of renewing licenses.10 Continuing education in Indonesia explained in Nursing Law No. 38 of 2014 in article 53, paragraphs 1 and 2 concerning the development of nursing practices carried out through formal education and non-formal education or continuing education, and it aims to maintain or enhance nurse professionalism.
One hospital in Jakarta, Indonesia, must always improve the quality and professionalism of nurses through formal education. This is because the proportion of nursing staff in regulation of the hospital is still not in accordance with the proportion of nursing staff that has been determined. The number of nurses in this hospital in 2017 was 2,135 with 80.05% having a Diploma of Nursing, 11.38% having a Nursing Professional designation, 6.18% having attended a School of Nursing Education, 1.66% having a Bachelor of Nursing, and 0.74% having a Master's/Specialists degree. The targeted proportion is 40% professionals and academics, consisting of 28% nursing professionals, 10% specialists, 2% master's degree holders, and one doctoral degree holder, while the remaining 60% of vocations should consist of Diploma of Nursing holders, dental nurses, and midwives. The hospital is also obliged to achieve the strategic plan of the Ministry of Health of the Republic of Indonesia for 2014–2019 related to a composition of 60% nursing professionals, 30% Diploma of Nursing holders, and 10% master's degree holders/nursing specialists. At present, the hospital has plans in 2018 to improve education: at least ensuring head nurses/nurse officers are nurse professionals at a rate of 100%, while a minimum of 40% of nurses should be nurse professionals.
The liberation of daily tasks is also an obstacle for nurses attending formal education, as it can lead to a reduced number of nurses and disrupted nursing services at the hospital. This has forced nurses to attend formal education while remaining in their job assignments or to work while remaining in accordance with the rules that apply in the hospital. Currently, among nurses attending school in 2017, 56 nurses attended formal education while working from among 2135 total nurses, though this does not consider the number of nurses who attended formal education while actively working in previous years.
Nurses are attending formal education while actively working face various challenges. A lack of peer support and funding and nurses’ work commitments are obstacles to participating in continuing education programs.11 Most of a person's motivation to work when studying is driven by the associated living and school costs.12,13 There are many negative impacts felt by these nurses, including fatigue, which leads to lessened alertness, an inability to concentrate when giving patient care, and medication errors that can cause problems for patient safety.14 The negative impacts felt by nurses can cause work-related injuries and can increase the costs of dealing with work injuries.15,16
The implementation of formal education is not only the responsibility of the individual nurse but also the responsibility of the nursing manager. The role and function of nurse managers are highly important in managing nurses who attend formal education while actively working. This involves unique challenges and meaningful experiences for these and nursing management. The nurse manager arranges the nurse schedules because nurses are not allowed to leave during work hours. The nurse manager must also evaluate the achievements of after nurses following continuing education, and a correlation was found between increasing the competences of nurses individually and in a group.17
The research related to the experiences of nurses attending formal education while actively working is mostly based on the nurse abroad perspective, whereas when based on the social and cultural characteristics of Indonesian nurses, new information from existing research can be elucidated. Therefore, this study aims to explore the experiences of nurses attending formal education while actively working.
MethodThis study used qualitative research with a phenomenological approach aiming to explore the experiences of nurses attending formal education while actively working. Fifteen participants were selected using the purposive sampling technique. Participants were determined based on data from the nursing department related to nurses attending formal education while actively working. Participants were determined to meet the inclusion criteria as follows: nurses who attending formal education (Bachelor of Nursing, Nursing Professional designation, Master of Nursing, and Nursing Specialist) while actively working in one general hospital in Jakarta, Indonesia; a Diploma in Nursing education at minimum; experience working for at least two years; physically and mentally healthy enough to be able to share and express their experiences; and a willingness to be voluntary participants with a statement of willingness in an informed consent letter.
The method of data collection was semi-structured in-depth interviews, where the researcher was the main instrument. The researcher as the main instrument tested himself by conducting a trial interview with one participant who met the specified inclusion criteria. This helped the researcher to improve the technique of asking questions and having conversations with participants. The researcher used interview guidelines so that each interview was similar to the others. In addition, the researcher tested the interview guidelines before use in the study. The interview guidelines were followed while conducting the interviews. The researcher refined the interview guidelines that had been tested, and he conducted interviews once with each participant. The interviews conducted in this study lasted around 30–60min per participant, and they were conducted both inside and outside of the hospital.
The researcher used Colaizzi's method to analyze the data because it is suitable for the process of data analysis in a phenomenological study. Data saturation was reached with the tenth participant, but the data collection process was terminated after the fifteenth participant. This is because the researcher wanted to gain data from a variety of educational backgrounds, ranging from Bachelor of Nursing, Nursing Profession, Master of Nursing, and Nursing Specialist.
The researcher validated the verbatim results with a member check of the participants. This is because the participant of one of the people can legitimately assess the credibility of the results of this research by confirming and clarifying the results of the interview transcript so that the participants obtain a match between the transcript data and the intended one. The researcher also validated the analysis results through peer review by another qualitative researcher. Peer review was conducted with one researcher who is also conducting qualitative research and who was willing and committed to taking the peer review process seriously. Peer review is carried out starting with reviewing the discovery of keywords, making categories, and forming the themes of the research results.
This study received ethics approval from the Ethics Committee in the Faculty of Nursing, Universitas Indonesia, and from the Ethics Committee in the Faculty of Medicine, Universitas Indonesia-RSCM.
ResultsParticipants in this study were 15 nurses from one general hospital in Jakarta, Indonesia, consisting of both females and males, married and unmarried individuals, and both clinical nurses and nurse managers. Participants of this study ranged in age from 23 to 57 years and in length of service from 2.5 to 37 years. They had varied levels of education, namely 10 with a Diploma of Nursing, three with a Nursing Professional designation, one Master of Nursing, and one Bachelor of Nursing. Participants also came from various units or departments, from the nursing management department, emergency room, outpatient unit, inpatient unit, operation room, and intervention room. They were also studying from various universities and education levels, including 10 nurses studying toward their Bachelor of Nursing, three toward their Master of Nursing, one toward a Nursing Specialist designation, and one toward a Nursing Professional designation.
The data analysis identified the main themes, which are (1) becoming a professional nurse, (2) self-funding for school costs, (3) feeling guilty about nursing assignments, and (4) lack of rest time.
Theme 1: Becoming a professional nurseThere are various reasons for clinical nurses to attend formal education while actively working, one of which identified in this study was the demand to be a professional nurse. This was expressed in the following statements: “Then like the demands of the profession too, school is now the standard to be a Nursing Profession, so I have to go there so I can be called a professional nurse…” (P, Clinical Nurse, 29 years old). “I go to school because of demands; nurses must have at least Nursing Profession…” (H, Clinical Nurse, 34 years old).
Nurses do not get support for the costs of school from the hospital, which causes nurses to use personal funds to attend formal education. This was expressed in the following statements: “So far, there has been no education funding or anything from the hospital, so we have to fund it ourselves purely…” (A, Nurse Manager, 33 years old). “Even though we are here for decades, we have also worked for a reason, because most nurses have applied for college, he said…there was no funds…but we were told to go to school again…” (D, Clinical Nurse, 39 years old). “They have allowed me to study permits, but I go home quickly, and I still deduct the remuneration; if, for example, I have permission to study, why is my remuneration deducted?” (C, Clinical Nurse, 25 years old).
The various problems faced by nurses attending formal education while actively working can threaten the safety of nurses and patients, including working with minimal remaining energy and having to leave assignments to other nurses. These cause nurses to feel guilty about their assignments, as expressed in the following statements: “The negative impact that I felt was that if it was too bad because I was tired of the campus to work with the remaining energy; finally, the nursing services were not optimal, so it's a dilemma…” (P, Clinical Nurse, 29 years old). “Many assignments must be passed to another nurse in the next scheduled or must be entrusted to friends who are there…” (F, Clinical Nurse, 26 years old). “Sometimes, every day is like a dilemma because we often come late; but in the hospital, they know we are nurses, not students, but at school they know we are students, not nurses…” (S, Clinical Nurse, 25 years old).
Nurses who are attending formal education while actively working feel a lack of rest time. This was expressed in the following statements: “…When we might go to sleep too, we are tired…sleep won’t work well if the assignment hasn’t been finished…” (A, Nurse Manager, 52 years old). “…Actually, I always go home every month, always go home during work; now, I take off weekdays, and I have to go to college so the point is I have a day off…” (C, Clinical Nurse, 25 years old).
Attending formal education is one of the efforts made by nurses to become professional. Increasing nurses’ knowledge, skills, attitudes, and behavior can be achieved through formal education,17 as nursing education has a significant influence on the development of professional values.18 A nurse's professional values reflect an understanding of how care should be given. Therefore, nursing management should support and encourage nurses to continue to learn and to change.19
Professional nurses have the responsibility and accountability to follow ethical principles and the professional standards of service as a whole. Nurses also must always try to improve their professional abilities both individually or together to increase knowledge, skills, and experiences, which are beneficial for the development of nursing. This aims to improve patient safety and outcomes and to reduce risks and adverse events.20,21
Nurses realize various benefits as professional nurses. Educated nurses can reduce the risk of patient death; can produce health outcomes equivalent to doctors for patients with various chronic health problems, especially for patients treated in primary care; and are more effective than medical care in promoting patient compliance with treatment and patient satisfaction.22 The most significant professional growth implications for practices include increasing retention and satisfaction, preventing turnover, and contributing to improving quality and patient safety.20
The policy of the hospital also does not provide cost assistance for nurses attending formal education while actively working. Education funding is an essential and inseparable component in the implementation of the teaching and learning process.23 It is almost certain that the education process cannot be carried out without adequate financial support.24 Based on Circular Letter No. 4 from the Ministry of Health of the Republic of Indonesia in 2013 concerning giving study tasks and study permits to civil servants in 2013, nurses who followed the study permit or attended formal education while working must pay for their own education.
This creates a reference for hospitals that do not have an obligation to provide tuition assistance to their nurses. However, one of the motivating factors for staff to continue education is the availability of funds.25 A lack of financial assistance is a factor that negatively influences participation in continuing education.26,27 An effective and efficient education budget is expected to produce effective human resources.23 This can be considered by the hospital when deciding whether to provide tuition assistance to nurses who practice formal education while working.
These nurses also receive remuneration deductions. Remuneration includes basic salary, benefits, facilities provided, pensions, and insurance based on the weighting of work, nursing services provided to patients, level of education, length of service, responsibilities, attendance, and position.28 The nurse manager determines the remuneration of nurses through a performance appraisal process.29 The remuneration given to employees is determined by the organization based on the criteria of performance, productivity, effort, skills, and difficulty of work.30
Remuneration is highly important for covering the cost of education and the needs of family nurses. Adequate remuneration is given to increase motivation, nurse performance, nurse satisfaction, work performance, and nurse retention so that it will improve the quality of health services in the hospital.31,32 However, a lack of rewards received by nurses can lead to a lack of motivation, job dissatisfaction, low performance, reduced productivity, low commitment, and a shortage of nurses due to high turnover rates.32,33
The activities of these nurses have an impact on the safety of nurses and patients. One indicator of occupational health and safety is the conditions of nurses.34 Based on Republic of Indonesia Law No. 44 of 2009 concerning hospitals, the physical imbalance among nurses can cause work accidents that harm not only nurses but also hospitals both directly and indirectly.
Nursing services as an integral part of health services contribute significantly to determining the quality and safety of patients in the service unit. Based on the National Hospital Accreditation Standards, the Indonesian Hospital Accreditation Commission in 2017 stated that hospitals are obliged to apply patient safety standards, and each patient has the right to safety while in hospital care. The hospital is also responsible for encouraging the implementation of programs to improve the quality and safety of patients and to strive to encourage the implementation of a quality and safety culture. Based on the Republic of Indonesia Law No. 38 of 2014 concerning nursing, in a safety culture, it is important that hospital staff members know that the operational activities of the hospital are high risk and that they show determination to carry out their duties consistently and safely. The nurse manager must be sensitive to the conditions of nurses who work with little energy, so the staffing function of the nurse manager is used to manage the nurses’ time effectively. Nursing managers also need to provide periods of staff relaxation, because continuous work will cause boredom.17
The lack of time faced by nurses attending formal education while they are working causes nurses to leave assignments to other nurses. Nurses provide nursing services in accordance with the code of ethics, standards of nursing services, professional standards, operational standards, standard operating procedures, and statutory provisions. Based on the Indonesian Nursing Ethics Code, one of the responsibilities of nurses is always to prioritize patient protection and safety in carrying out maintenance tasks by considering their ability to receive or assign responsibilities related to nursing care. Nursing managers can monitor the nursing care provided by the nursing staff.17 The main factor in ensuring the quality of nursing care is supervision, which leads to the personal and professional development of nurses.35
The intense activity of nurses in continuing education has led to a lack of rest time. Someone who attends formal education while actively working requires more time is more tired and is under more stress.36 Nurses can feel fatigue, which results in lessened alertness and a lesser ability to concentrate when providing patient care, which can lead to medication errors and problems for patient safety.14 The negative impact felt by nurses can result in work-related injuries and increased costs of overcoming work injuries.37
Conclusion and recommendationOne effort taken to become a professional nurse is attending formal education without having to leave daily duties as a nurse. This is because there is no cost assistance from the hospital, so nurses must finance their education independently to improve their knowledge through formal education. Various challenges were also faced by nurses attending formal education while actively working, such as feeling guilty about nursing duties that are not carried out optimally and having a lack of rest time, which can affect the safety of nurses and patients.
Future studies may explore the incidents or occupational safety, quality of life, patient and nurse manager experiences, nurse educator experiences, the correlation between nurse achievements and individual or group nurse competencies, and differences between nurse educators and clinical nurses among nurses attending formal education while actively working. As well, this study can be done using different research methods, such as quantitative and mixed methods research.
Conflict of interestsThe authors declare no conflict of interest.
This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1843/UN2.R3.1/HKP.05.00/2018.
Peer-review under responsibility of the scientific committee of the Second International Nursing Scholar Congress (INSC 2018) of Faculty of Nursing, Universitas Indonesia. Full-text and the content of it is under responsibility of authors of the article.
