Policy Reform in Nurse Education and Its Implementation in the Caribbean Region
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Policy reform in nurse education and its implementation in the Caribbean region Andrea F. Brathwaite Submitted in accordance with the requirements for the degree of Doctor of Education School of Education University of Sheffield October 2017 Andrea F. Brathwaite Thesis Abstract In 2006, the Caribbean Community (CARICOM) – a federation of sovereign Caribbean states – decided that the Bachelor of Science in nursing degree would be the standard qualification for entry to nursing practice in its English-speaking member countries. Indications were that by 2011 all of the English-speaking states had not implemented the regional policy. This research study was conducted to reveal the origin and nature of the 2006 CARICOM nursing education reform, trace its pattern of implementation, and determine the implications of that pattern for the coverage and coherence of healthcare in the region. An interpretive study with a multiple case design was conducted. Six case units were investigated through a staged approach to this empirical study. The research drew on the findings of interviews with selected policy actors, and on findings from the review of relevant documentary sources. The main findings were that the reform was not fully adopted in the region; that system tensions delayed its implementation; and that country-specific factors produced the variation in its adoption by member states. These findings have implications for the harmonization of nursing across CARICOM and, by extension, for CARICOM’s functional cooperation in nursing services. They also have implications for the region’s accomplishment of the World Health Organisation’s objective of universal access to quality healthcare – part of its Universal Health Coverage by the year 2030 agenda. The results should be useful to Caribbean and international health and education policy scholars and actors. Key words: nursing, higher education, education reform, policy implementation, Caribbean, CARICOM ii Andrea F. Brathwaite Thesis Acknowledgements “If I’ve seen further, it’s by standing on the shoulders of giants.” Sir Isaac Newton, 1676 In tribute to the Caribbean nurse leaders of the past and those who continue their struggle today. With profound gratitude to this study’s participants, my supervisors, and my supportive family and friends. Thanks for letting me stand on your shoulders! iii Andrea F. Brathwaite Thesis Table of Contents Page Abstract ........................................................................................................................ ii Acknowledgement....................................................................................................... iii Appendices .................................................................................................................. ix List of Tables................................................................................................................ x List of Figures ............................................................................................................. xi List of Commonly Used Abbreviations ..................................................................... xii PART 1: Introduction and Background ................................................................. 1 Chapter 1: Introduction to the Research ............................................................... 2 Aim and importance of the research ........................................................................ 2 Core and supplementary research questions ........................................................... 3 Research design, methods and data sources ............................................................. 3 Presentation of the findings ..................................................................................... 4 Significance of the research ..................................................................................... 4 Structure of the thesis ............................................................................................... 5 Chapter 2: The Caribbean Community: Structure, History and Responsibility for Nursing .................................................................................................................. 6 CARICOM members, structure and governance .................................................... 6 Mobilization to advance nursing in the Caribbean ............................................... 13 Federation, independence, political union and their influence on nursing ........... 14 Governance of nursing in the Anglophone Caribbean .......................................... 16 Perspectives on Caribbean policy-making ........................................................... 17 Chapter 3: The CARICOM 2006 BScN Reform .................................................. 20 Contemporary economic and social features of CARICOM ................................. 20 Origin and nature of the BScN reform ................................................................... 24 RNB’s BScN surge ................................................................................................ 27 Building the model curriculum ............................................................................. 29 iv Andrea F. Brathwaite Thesis Expectations and plans for implementation ........................................................... 31 Contemporary provision and governance of nursing in CARICOM ..................... 32 PART 2: Conceptualizing the Research ................................................................ 38 Chapter 4: Features and Dynamics in Policy Systems ........................................ 39 Understanding policy dynamics .............................................................................. 39 Actors in policy systems ......................................................................................... 41 Contextual and actor influences on policy implementation .................................... 42 Policy characteristics and policy outcomes............................................................. 43 Policy dynamics in federal systems ........................................................................ 46 Insight from education policy scholars ................................................................... 48 Planning policy implementation ............................................................................. 50 Summary ................................................................................................................. 51 Chapter 5: Perspectives of Policy: Models and Processes ................................... 52 Top-down perspectives ........................................................................................... 52 Multi-directional perspectives on policy and power ............................................... 57 Health policy analysis ............................................................................................. 60 The Policy Evolution Model ................................................................................... 61 Explanation of the model’s elements ...................................................................... 63 Purpose and scope of the model .............................................................................. 68 Chapter 6: Research Design, Methodology and Methods .................................. 69 Research questions and design ............................................................................... 69 Positionality and issues of confidentiality ............................................................. 71 Ethics procedure .................................................................................................... 74 An interpretive design…. ....................................................................................... 75 A staged approach .................................................................................................. 79 Stage 1 – Desk Review .................................................................................... 80 Computer-mediated communication for data collection .................................. 81 Selection of and access to participants ............................................................. 82 Stage 2 – Interviews and documentary review ................................................ 87 v Andrea F. Brathwaite Thesis Character and conduct of interview studies ...................................................... 88 Search, collection and analysis of documents ................................................... 92 Stage 3 – Analysis and synthesis of the findings .............................................. 94 PART 3: Findings and Implications of the Research .......................................... 98 Chapter 7: Introduction to Part 3 ......................................................................... 99 Desk review findings.............................................................................................. 99 Key features of the context .................................................................................. 104 Stage 2: Conducting the interviews and document analysis ................................ 105 Introducing the empirical findings ...................................................................... 106 Chapter 8: Early Engagers: Jamaica and The Bahamas ................................ 108 Jamaica’s nursing education context and sample description .............................. 108 Jamaica’s empirical