Continuing Professional Education: Exploring the Experience of Community Nurses Working on a Small Remote Island Julie Anne Lemprière A thesis submitted to The University of Gloucestershire in accordance with the requirements of the degree of Doctorate of Education in the Faculty of Applied Sciences. June 2013 Abstract Qualified nurses require equitable access to continuing professional education (CPE) that is responsive to the needs of learners, employers and most importantly clients. There is scant attention paid to the CPE custom of community nurses, with research in the experience of island-based nurses mainly limited to the Mediterranean and under-developed islands, or of nurses working in the Scottish Isles. The community nurses in question are employed by a charity working outside the National Health Service (NHS), based on an island with a unique model of healthcare that is more medicalised and institutionalised than the United Kingdom NHS. Semi-structured, one-to-one interviews were conducted with sixteen community nurses, and two focus groups undertaken, one with nurse managers and the other with qualified nurses. Interview data were analysed using Interpretative Phenomenological Analysis, a method new to education research, and not yet recorded in relation to nurse education. Findings indicated an ageing workforce, with ageism hindering access to CPE. Geographical isolation coupled with a lack of access to tertiary education dictated CPE to fulfil professional development. Charitable status and limited CPE funding resulted in a third of nurses applying for sponsorship via local or national agencies, this was not found elsewhere in the current literature. This research contributes to the knowledge relating to nurse CPE, confirming the transferability of existing literature relating to geographical remoteness, barriers and outcomes of formal study to community nurses. It advances the current knowledge base with regard to small island infrastructure effecting access to CPE, funding formal education for nurses working outside the NHS, and silo working within the community setting. Further research is required to explore the experience of community nurses under the age of 30 years not represented within this study, who will be the future workforce when older nurses retire. These findings are of particular significance to the Jersey Health and Social Services Department who are currently redesigning the future health and social care system on the island based on a community model, nurse educators, the charity and its qualified nurse employees, and finally the island population. i Acknowledgements Being a doctoral student can be an isolating experience, particularly when living on a remote island with no university or academic library. Therefore, I wish to thank my supervisors, Professor Diane Crone, Dr Lindsey Kilgour and Mr Harry Cowen for their long distance support, guidance and encouragement in the completion of this thesis. The irony of my geographical situation was certainly not lost on them! I would like to say a big ‘thank you’ to my husband Chris for taking on the domestic responsibilities, giving up holidays for the past seven years and for his graciousness in embracing all the financial expenses that enabled me to follow my dream. Thanks also go to my parents for their utter belief that I could achieve such a momentous task. ‘Merci beaucoup’ to my colleague Annie Le Borgne-Garner for helping me with the French translation and giving her time so freely. I am also grateful to my dear friend Helen Patrick for providing me with accommodation, plenty of home-cooked goodies and necessary retail therapy when I travelled to the mainland for supervision. Lastly, I wish to express sincere gratitude to my colleagues who volunteered to participate in this research, whose experiences and willingness to share them provided the foundation and inspiration for this thesis. ii Contents Page Abstract …………………………………………………………… i Acknowledgements ……………………………………………… ii Contents …………………………………………………………… iii-vii List of Figures …………………………………………………….. viii List of Tables ……………………………………………………… ix List of Appendices ………………………………………………... x List of Acronyms ………………………………………………….. xi-xii CHAPTER 1: INTRODUCTION ………………………………… 1 Aim of the research ……………...………………...…………….. 1 Context of the thesis ……………..………………………………. 2 Community nursing ……………..………………………………... 6 My interests in relation to CPE ……………………..…………… 7 Overview of the thesis ………………..………………………….. 8 CHAPTER 2: LIFELONG LEARNING ………………………… 11 Lifelong learning………………………..…………………………. 12 Lifelong learning and the National Health Service ……………. 19 Distinctions between CPD and CPE ………………………..….. 24 The integration of lifelong learning into the NHS ……………… 28 CPE and the theory / practice gap ……………..………………. 33 Outcomes of CPE on nursing practice ………..……………….. 35 Methodological considerations…………..………………………. 42 Chapter summary …………….………………………………….. 44 CHAPTER 3: CONTINUING PROFESSIONAL EDUCATION 46 Search strategy ……………………………………..……………. 47 Personal factors …………………………………..……………… 49 Organisational factors ……………………………..…………….. 53 Geographical factors………………………………..……………. 59 Outcome of CPE on nurses ………………………..…………… 67 Methodological considerations ……………………..…………… 70 Chapter summary ………………………………………………… 72 CHAPTER 4: METHODOLOGY AND METHODS……………. 75 iii Framework for the study ………………..……………………….. 75 Constructivism ………………….………………………………… 76 Interpretative Phenomenological Analysis …………………….. 77 Phenomenology ………………………………………….. 77 Hermeneutics …………………………………………….. 78 Idiography ………………………………………………… 79 Justification of the approach of the study……………… 80 Critique of research using IPA …………………………. 81 Data Collection Method …………………………………………. 82 Semi-structured interviews ……………………………… 83 One-to-one interviews …………………………………… 84 Comparison with other qualitative data collection tools 85 Data Collection Process ………………………………………… 87 Assessing the quality of qualitative research …………. 87 Sampling ………………………………………………….. 89 Interview schedule development ……………………….. 91 Interview process ………………………………………… 91 Data analysis …………………………………………...... 92 Transcription ……………………………………… 92 Coding …………………………………………….. 92 Themes ……………………………………………. 93 Role of the researcher …………………………… 94 Writing up the findings …………………………… 95 Ethical Considerations …………………………………………… 95 Research participation …………………………………… 95 Informed consent ………………………………………… 96 Anonymity ………………………………………………… 96 Confidentiality …………………………………………….. 97 Beneficence ………………………………………………. 97 Non-maleficence …………………………………………. 97 Reflexivity …………………………………………………………. 98 Chapter summary ………………………………………………… 98 CHAPTER 5: PRESENTATION OF RESEARCH FINDINGS.. 100 Demographic data of participants ………………………………. 100 Conceptualisation of community nurses’ CPE experiences..... 104 iv Undercurrents affecting CPE …………………………………… 106 Small Island ………………………………………………. 107 Geographical isolation …………………………… 108 Professional isolation ……………………………. 109 Types of CPE accessed ………………………… 111 Travel issues ……………………………………… 112 Island Infrastructure ……………………………………… 114 Island health service …………………………….. 115 Professional rivalry ………………………………. 116 Working for a charity …………………………….. 118 Staff appraisals & personal development plans.. 122 Educational opportunities …………..…………… 123 Healthcare Culture ……………………………………….. 126 Workplace culture………………………………… 129 Attitude towards CPE.……………………………. 132 Getting underway with CPE.…………………………………….. 134 Lack of skills for academic study ……………..………… 134 Motivation ………………………………….……………… 136 Making Headway with CPE ………………..……………………. 138 Family support …………………………..………………... 139 University support ………………………………..………. 139 Knowing the Ropes following CPE ……………….……………. 140 Personal outcomes following CPE …………………..…. 141 Professional outcomes following CPE………………….. 141 Change own practice following CPE ………..….. 142 Change colleagues practice following CPE …… 143 Improved patient care following CPE …………… 146 Chapter summary ………………………………………………… 147 CHAPTER 6: DISCUSSION OF RESEARCH FINDINGS ....... 151 Undercurrents affecting CPE …………………...………………. 151 Small island …………………..……………………........... 151 Geographical isolation …………………………... 152 Professional isolation ……………………………. 153 Types of CPE accessed by community nurses... 154 Local CPE …………………………………………. 154 v CPE in the UK ………………..…………………… 155 Distance learning …………………………………. 155 e-learning ……………………..…………………... 156 No CPE undertaken …………………..…………. 157 Travel issues………………………………………. 157 Island Infrastructure………………………………………………. 158 Island Health Service ……………..….………………….. 159 Professional Rivalry………………………………………. 160 Working for a charity ……………………………………... 161 Staff Appraisals & Professional Development Plans …. 164 Educational opportunities ………................................... 165 Healthcare Culture ……..………………………………………… 166 Workplace culture …………………………..……………. 168 Attitude towards CPE ……………………………………. 170 Getting underway with CPE ………………………………..…… 171 Lack of academic study skills …………………………… 171 Motivation ……………………………………..………….. 173 Making headway with CPE ………………..……………………. 175 Family support ……………………………..…………….. 175 University support ……………………………………..… 175 Lack of colleague support ………………………………. 176 Knowing the ropes following CPE ……………..……………….. 177 Personal outcomes following CPE …………..…………. 177 Professional outcomes following CPE …………………. 178 Change own practice following CPE ……..……. 178 Change colleagues practice following CPE …… 179 Improved patient care following CPE …..……… 183 Chapter summary ………………………………………………… 184 CHAPTER