This is the author’s version of a work that was submitted/accepted for pub- lication in the following source: Black, K.E. & Bonner, A. (2011) Employer-based support for registered nurses undertaking postgraduate study via distance education. Nurse Ed- ucation Today, 31(2), pp. 163-167. This file was downloaded from: http://eprints.qut.edu.au/43798/ c© Copyright 2011 Elsevier Notice: Changes introduced as a result of publishing processes such as copy-editing and formatting may not be reflected in this document. For a definitive version of this work, please refer to the published source: http://dx.doi.org/10.1016/j.nedt.2010.05.012 http://eprints.qut.edu.au/view/person/Bonner,_Ann.html http://eprints.qut.edu.au/43798/ http://dx.doi.org/10.1016/j.nedt.2010.05.012 EMPLOYER-BASED SUPPORT FOR REGISTERED NURSES UNDERTAKING POSTGRADUATE STUDY VIA DISTANCE EDUCATION 1 of 10 ABSTRACT Previous literature has focused on the need for support of undergraduate nursing students during clinical placements. Little is known about the support provided by employers for registered nurses (RNs) who pursue further education This study sought to identify and describe the types, levels and perceived need for support in the workplace for RNs as they undertake further postgraduate nursing study by distance education (DE). Using an exploratory descriptive design a self-report questionnaire was distributed to a convenience sample of 270 RNs working in one acute care public hospital in Tasmania, Australia. 92 questionnaires (response rate 34%) were returned with 26 (28%) reporting being currently enrolled in further study by DE and a further 50 (54)% of RNs planning future study. Results revealed that 100% of participants with a Masters degree completed this by DE. There were differences between the support sought by RNs to that offered by employers, and 16 (34%) who had done or were currently doing DE study, received no support to undertake DE. There was an overwhelming desire by RNs for support; 87 (94%), with a majority believing some supports should be mandatory 76 (83%). This study may encourage employers to introduce structured support systems that will actively assist nurses to pursue further study. KEY WORDS Nursing, post-graduate study, distance education, workplace support EMPLOYER-BASED SUPPORT FOR REGISTERED NURSES UNDERTAKING POSTGRADUATE STUDY VIA DISTANCE EDUCATION 2 of 10 BACKGROUND There is general recognition of the importance of continuing or life-long learning for all nurses (Department of Education Science and Training [DEST] 2002; Jarvis 2005; Royal College of Nursing Australia [RCNA] 1998). Following completion of initial nursing courses leading to registration (commonly at an undergraduate level), post-graduate education has been suggested as the appropriate avenue for development of expertise in nurses (Pelletier et al 2000). In Australia, the Nursing and Midwifery Labour Force Survey has defined further education as including hospital-based certificates and tertiary qualifications in nurse management, clinical practice and nursing education while excluding in-service/continuing education sessions, refresher or re-entry courses or courses of less than 6 months duration (Australian Institute of Health and Welfare [AIHW] 2008). The continuing and expanding provision of post-qualifying courses for nurses is a clear demonstration of the acceptance of the value and importance of further education. In recent years, other reasons for further education in nursing have included an increasing shortage of nurses, competition in the labour market, and recruitment and retention issues (DEST 2002). The ‘Magnet Hospital’ principles in the United States note the importance of education support for nursing staff as essential to staff satisfaction and consequent staff retention (Kramer & Schmalenberg 2005; McClure 2005; Westendorf 2007). The Australian Evaluation and Quality Improvement Program [EQUiP 4] for hospital accreditation, recognises that staff educational support, to achieve skills and maintain competence, is essential for quality health care (Australian Council on Healthcare Standards [ACHS] 2008). Quality health care should also be based on evidence at planning, development and delivery stages (ACHS 2008), and there has been a trend towards emphasising the importance of evidence-based practice within clinical nursing. This is now paralleled by recognition of the importance of evidence-based nursing education (Clark 2005; Yonge et al 2005). Benner (1984; 2004) contends that development of expertise occurs within the practice setting. The importance of clinical and workplace learning has thus long been recognised. Increasingly, distance education (DE) is the vehicle for the delivery of further education for nurses (Cook et al 2004). Distance, time and ability to attend classes are factors that limit nurses’ ability to engage in post-qualifying study, and DE is seen as an obvious solution to this (Cook et al 2004; Oehlkers & Gibson 2001; Pym 1992). Education providers and students are finding that the increasing use of information communication technology is conducive to DE (Adams & Timmins 2006; Bruskiewitz & De Muth 2005; Hollis & Madill 2006; Janes 2006; Shovein et al 2005; Zalon & Meehan 2005). DE takes many forms but can include video conferencing, resource packages along with on-line components (such as discussion boards, Wikis, podcasts, and email). DE, especially online, offers increased access to education for nurses who find it difficult (or impossible) to attend traditional on-campus classes. Previous studies into DE for nurses’ have focussed on support structures provided by education providers (Lawton 1997; Oehlkers & Gibson 2001; EMPLOYER-BASED SUPPORT FOR REGISTERED NURSES UNDERTAKING POSTGRADUATE STUDY VIA DISTANCE EDUCATION 3 of 10 Pelletier et al 2003; Pym 1992). According to Fortin (2007), students who studied via DE frequently reported feeling isolated and had to develop routines to foster self-motivation and study habits without the structured routine and collegial support provided in a classroom. Other authors acknowledged that to study by DE whilst working is problematic for life/work balance (Cragg, Andrusyszyn & Fraser 2005; Evans et al 2007; Oehlkers & Gibson 2001; Pym 1992). One of the ways DE students aim to achieve this balance is with help or support from a variety of sources. Oehlkers and Gibson (2001) classified support as formal (provided by the educational institution) or informal (provided by family, friends, mentors, colleagues, employers). Cragg, Andrusyszyn and Fraser (2005) previously examined the support received by professional women whilst studying by DE. Findings concluded that support comes from the woman’s family, the educational institution and their employer; however Cragg et al’s study focussed more on the support received from the family and educational institution rather than workplace support. The nurse education literature reveals limited discussion on the place of employment-based support for nurses undertaking post-qualifying study by DE. In separate reviews, Long and Johnson (2002) and Yonge et al (2005) found little on learning in practice and no research specifically on workplace support for RNs undertaking study by DE. Against the background of the promotion and, in some states, the mandating of further education for RNs in Australia, this is a significant omission. There is clearly a need to examine how work-based education support can be effectively provided. Workplace support needs to be identified and described, thus allowing employers to seek ways to create or strengthen support structures. This paper reports on a study into the importance of workplace-based support from the nurses’ perspectives whilst studying by DE. METHODS Study Design and Aims This study sought to identify different modes of employer-based support for RNs who were undertaking further study by DE, and to explore, from the point of view of participants, whether the existence or absence of such support had any bearing on the uptake, ease or difficulty of undertaking and completing a formal program by DE. In this study, DE was defined as education that was not time- or place-specific and included correspondence courses, televised or videotaped lectures, online courses (internet and e-mail), where the education institution was different to the employing institution. Sample and Setting In June 2008, a convenience sample of 270 Registered Nurses (RNs) employed at a major metropolitan hospital in Tasmania, Australia was provided with a self- report questionnaire. The sample was drawn from four wards (medical, surgical, Emergency Department and Anaesthetics / Peri-Operative Department). These were selected to provide a range of nursing contexts and also to capture areas where there was no or limited local provision of further education. EMPLOYER-BASED SUPPORT FOR REGISTERED NURSES UNDERTAKING POSTGRADUATE STUDY VIA DISTANCE EDUCATION 4 of 10 The Tasmanian Human Research Ethics Committee provided institutional ethics approval. Information sessions were provided in each area to inform RNs about the study and to extend an invitation to participate. Flyers were posted in ward offices and staff rooms to encourage participation. Packages containing the questionnaire and associated explanatory information, including informed consent and ethics approval, were mailed internally to potential participants. Data Collection A questionnaire was specifically developed for this study. Content validation of the questionnaire was determined through a pilot study with 13 RNs from one work area (Nephrology Department) who were asked to complete the draft questionnaire specifically looking at readability and applicability. The questionnaire was modified based on the feedback. It became apparent from the pilot that some RNs had done more than one DE course. Thus the question on types of support sought, received or offered, during a DE course was replicated. The final questionnaire comprised three sections. Firstly demographic information such as location of initial nursing education (i.e. hospital or university); number of years as a registered nurse (RN); current level (position); main role in current job; and nursing qualifications held. The second section focussed on relevance of qualifications to current job; whether the qualification was undertaken by DE; current enrolment in nursing related study; types of course (i.e. bachelor degree, postgraduate certificate, postgraduate diploma, masters, doctorate); and relevance to work. Gender, age and specific area worked were intentionally omitted to ensure anonymity due to the possibility of later identification by the first author. The third section focussed on workplace support with fifteen support types specified plus a category for ‘other’. Prior to data analysis, the types of support were grouped as i) cost related (fees, study leave and material resources purchased); ii) system related (clinical placements, roster requests, study group, material resources available and preceptorship); iii) academic related (study skills, IT assistance, literature searches and formal, e.g. proofreading and referencing); iv) social / emotional related (emotional, study buddy, sounding board and mentor); and v) other. The questionnaire enabled nurses to indicate different responses if they had undertaken more than one course by DE. Data Analysis Statistical Package for the Social Sciences (SPSS 14.0) was used for data analysis. Descriptive statistics including cross tabulations and Chi Square analysis were computed: significance was set at p < 0.05. RESULTS Demographic Data, Qualifications and Distance Education The response rate was 34% (n=92). Sixty four percent of participants were initially tertiary educated, while 83% held a minimum of a bachelor degree and over 40% have further nursing qualifications, 22% of these were gained by DE. In this study, 66% of participants were level 1, 20% level 2 (both levels are clinically-based) and 13% level 3 (management or education). Over half the EMPLOYER-BASED SUPPORT FOR REGISTERED NURSES UNDERTAKING POSTGRADUATE STUDY VIA DISTANCE EDUCATION 5 of 10 participants (n=52, 56%) had more than 10 years full-time equivalent (FTE) nursing experience (see table 1). 28% of participants reported being currently enrolled in further study by DE, with the majority in either a post-graduate certificate or a post-graduate diploma. 88% of participants studying by DE reported that the qualification would be relevant to their current job. Almost half the study participants (46%) plan future study by DE. Table 2 reveals results for distance education. Workplace Support for Nurses Studying by Distance Education In this study, fifteen types of support were identified including course fees, study leave, resources purchased or available, roster requests, clinical placements, study buddy, sounding board, study group, study skills (literature searches, Information Technology and formal), mentorship, preceptorship, emotional, plus other. Participants indicated a low level of employer support. 28% of participants who had done, or were currently doing DE, received no support, whilst a further 19% received only one type of support. Of these same nurses 59.5% had sought support whilst for 71.4% no support was offered. Table 3 illustrates the types of support reported during current / most recent course and earlier course (for those who have done more than 1 by DE). In current / most recent: study leave (36%), course fees (31%) and roster requests (31%) were the support types most frequently received; while the most frequently sought were: mentor (24%) and study buddy (24%). The most frequently offered were study leave, study group and emotional (each 10%). Also of note was the number of support types that were sought more often than received. Study group was the only support offered more than it was sought. For those participants who have completed more than one DE course, mentorship (30%) was the most frequently received support. Study leave, sounding board and mentorship (each 20%) were the most frequently sought types of support. No support was offered to RNs during earlier DE courses. A comparison between support sought and offered in this study highlights the gap between the two with very little support of any kind offered for either current or previous DE students. According to participants in this study, there was little support offered by nursing management or from the health department for DE study. Support for Distance Education in an Ideal Workplace The final aspect explored was the support nurses would like or believe should be mandatory, with 94.6% of participants reporting they would like to receive (liked) three or more types of support and 73% believing some forms of support should be compulsorily provided by the employer (mandatory). Table 4 shows support RNs would like or they believe should be mandatory. Support liked and mandatory were compared between those currently enrolled (n =26) with those who have previously undertaken DE study (n =21). There was a difference between liked and mandatory support to this question. The most frequently liked support types were; course fees (74%), roster requests (61%), study leave (60%) and study groups (58%) whereas mandatory support types were; study leave (75%), clinical placements (62%), roster requests (60%) and formal clinical EMPLOYER-BASED SUPPORT FOR REGISTERED NURSES UNDERTAKING POSTGRADUATE STUDY VIA DISTANCE EDUCATION 6 of 10 supervision (preceptorship) (47%). However, none of these reached statistical significance. DISCUSSION Fostering further study amongst nurse employees is an important recruitment and retention strategy for hospitals (Kramer & Schmalenberg 2005; McClure 2005; Westendorf 2007). Encouragement and support for nurses to undertake further study is also a key characteristic of ‘Magnet’ hospitals (Kramer & Schmalenberg 2005; McClure 2005; Westendorf 2007). This study found that in this workplace nurses received little support for further study by DE. There were clear differences between what nurses wanted and what they received by way of support. Little was offered and what was received was apparently a result of nurses’ initiative, demonstrated by the nurses having to seek support. In addition, the majority of nurses would either like or believe support should be mandatory and yet only a minority of nurses actually received or were offered support. Some of the differences in frequency seem to be related to whether the support is cost, system, social/emotional or academic-related. Oehlkers and Gibson (2001) described support as resources that nurses received to enable them to undertake further education (e.g. fees, roster support). In this study some cost-related support (fees and resources purchased) were generally reported with greater frequency under sought and liked than offered and mandatory. Similarly Cooley (2008) found that when nurses pursued further education more support in terms of study leave and funding was needed. Cost issues in health and education have been identified as a constraining factor in supporting clinical learning (Wellard, Williams & Bethune 2000). Interestingly study leave was more frequent under mandatory than liked and almost identical under sought and offered, with a relatively high frequency under received. This indicates an expectation from the participants for this type of support. Having an expectation that support ought to be provided may reflect the nurses’ in this study belief that study leave is part of the current leave allowance entitlement. While study leave is provided for residential (on-campus) components of courses and to sit examinations, it is not recognised by employers that study leave is also needed to complete courses through DE modes of learning. This is an interesting and hidden aspect to DE courses and that RNs undertaking these course seem to be disadvantaged. In this study course fees and resources may have been more frequent under mandatory had the question posed ‘an ideal workplace’. The Tasmanian Department of Health recently announced the availability of post-graduate scholarships for RNs wishing to undertake post-graduate certificates or diplomas through the University of Tasmania. It could be inferred by the provision of scholarships is the purported increased staff satisfaction and the flow on to the department due to higher staff retention rates and lower overall staffing cost-savings (Westendorf 2007). However, RNs wishing to study at other universities are not supported, and this will hinder some nurses undertaking post-qualifying courses in some specialty fields. This study found that the system-related support (roster requests, preceptorship and clinical placements) had very similar frequencies for liked and mandatory. This was an unsurprising result given that participants would recognised the ease EMPLOYER-BASED SUPPORT FOR REGISTERED NURSES UNDERTAKING POSTGRADUATE STUDY VIA DISTANCE EDUCATION 7 of 10 with which such system support could be provided. However these forms of support were sought far more frequently than offered, indicating that reality does not yet reflect need in this workplace. Definitions of support have included advising, counselling, enabling and advocating (Lawton 1997). Although Lawton was referring to the educational institution as support provider these could equally be provided in the DE student’s workplace through the aegis of informal collegial relationships. In this study, social and emotional-related support (emotional, mentorship, study buddy, study group and sounding board) was generally sought more often than offered or received and also more frequently liked than mandatory. A majority of participants may believe social-emotional support cannot be mandated, as they are all dependent on naturally occurring, inter-personal relationships. A workplace culture can, however, be cultivated in which further study and care of colleagues are highly valued. Such a culture would in effect provide an employer mandate for less formal modes of support such as these for nurses undertaking further study. A values statement at institution level, backed by action at all nursing levels, promoting further study and collegial support would be of benefit within the workplace. In this study, digital information and communication technologies were referred to as information technologies (IT) as this term was in general usage at this hospital. Within nursing workplaces IT support is generally systems orientated, for example electronic patient records or online pathology results (Eley et al 2008; Simpson 2007). The specific IT support needed by nurses as they study may be more oriented towards less workplace specific programs such as word- processing and spreadsheet skills. The reasons for study skills (IT assistance, literature search and proof reading / referencing) being reported more for liked than mandatory are likely to relate to the academic nature of the support. Respondents may have believed this type of support is more within the remit of education providers than that of employers and that these are not readily available within the workplace. Occasionally these types of support may appear serendipitously if a colleague has the ability, time and willingness to assist. A formal relationship between workplace and education providers may increase access to these forms of support for nurses who are studying. Lawton (1997) contends that a structured approach to supporting DE learners will ensure the support is more effective. If employers develop formal frameworks within their systems to identify and support nurses who are studying through DE, the learning outcomes can be enhanced. A system of support must start at the level of organisational culture and look at cost-benefits associated with increased staff expertise, satisfaction and retention. A system can be designed to value workplace study and encourage collegial support and should include formal partnerships with education providers. The corollary for the employer will be better prepared practitioners with improved recruitment and retention rates. Limitations This was an exploratory study using convenience sampling from one hospital, and although we had a response rate of 34%, the sample nevertheless is consistent with the demographic profile of the Australian nursing workforce EMPLOYER-BASED SUPPORT FOR REGISTERED NURSES UNDERTAKING POSTGRADUATE STUDY VIA DISTANCE EDUCATION 8 of 10 (AIHW 2008), so the potential for non-response bias is slow (Polit & Beck, 2010). We do, however, caution that the generalisability of these results to other countries may be limited. In addition the scope of the study did not explore support for RNs who had studied traditional on-campus courses. Lastly, there were low numbers of participants who reported withdrawing from DE courses thereby limiting the ability to explore the relationship between support and the non-completion of a DE course. Potential Contribution of This Study These research findings can help employers and distance education providers improve their understanding of the factors that impinge on working RNs when they undertake further study by DE. Such understanding will allow systematic planning of support networks with specific areas of responsibility lying within the remit of the workplace or education provider or both. Employers seeking to improve recruitment and retention of experienced RNs may be encouraged to further develop workplace cultures that value study, through direct action not simply inert ‘values statements’. Future Research The findings of this study warrant further research. For instance, whether workplace support has a direct effect on the uptake and completion of study by nurses, either by DE or face-to-face course delivery and how workplace support impacts on nurses’ stress levels when they study. Rural and remote nursing employees may be at a disadvantage in terms of access to face-to-face further education. This aspect warrants further research to determine the impact of workplace on the provision of workplace support for RNs studying by DE. CONCLUSION Employer support for RNs studying by DE has generally been absent in the extant nurse education literature. From the nurses’ perspective, current support arrangements do not correspond to what is desired or should be required. If employers are to be credible advocates of further education this study suggests that there are simple and practical measures that could be taken to support nurses as they study by DE. EMPLOYER-BASED SUPPORT FOR REGISTERED NURSES UNDERTAKING POSTGRADUATE STUDY VIA DISTANCE EDUCATION 9 of 10 REFERENCES ACHS – see Australian Council on Healthcare Standards Adams, A., Timmins, F., 2006. Students’ views of integrating web-based learning technology into the nursing curriculum: a descriptive study. Nurse Education in Practice 6, 12-21 AIHW – see Australian Institute of Health and Welfare Australian Council on Healthcare Standards, 2008. EQUiP 4, Functions, Standards and Criteria, Table 4: Mandatory Criteria, viewed online at Australian Institute of Health and Welfare, 2008. Nursing and midwifery labour force 2005. National health labour force series no. 39. Cat. no. HWL 40. Canberra: AIHW Benner, P., 1984. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley Publishing Company, Inc, California Benner, P., 2004. Using the Dreyfus Model of Skill Acquisition to describe and interpret skill acquisition and clinical judgement in nursing practice and education. Bulletin of Science, Technology and Society 24 (3), 188-199 Bruskiewitz, R., De Muth, J., 2005. Availability and acceptability of distance- learning delivery systems for continuing pharmaceutical education. American Journal of Pharmaceutical Education 69 (2), 169-175 Clark, E., 2005. Commentary on Research in Nurse Education Today: Do we meet our aims and scope? Nurse Education Today 25, 609-611 Cook, G., Thynne, E., Weatherhead, E., Glenn, S., Mitchell, A., Bailey, P., 2004. Distance learning in post-qualifying nurse education. Nurse Education Today 24, 269-276 Cooley, M. C., 2008. Nurses’ motivations for studying third level post- registration nursing programmes and the effects of studying on their personal and work lives. Nurse Education Today 28, 588-594 Cragg, C.E., Andrusyszyn, M.-A., Fraser, J., 2005. Sources of support for women taking professional programs by distance education. Journal of Distance Education Spring, 20 (1), 21-38 DEST – see Department of Education, Science and Training Department of Education, Science and Training, 2002. National review of Nursing Education, DEST no. 6880 HERC02A, Canberra viewed 18 August 2007 Eley, R., Fallon, T., Soar, J., Buikstra, E., Hegney, D., 2008. The status of training and education in information and computer technology of Australian nurses: a national survey. Journal of Clinical Nursing 17, 2758-2767 Evans, W., Brown, G., Timmins, F., Nicholl, H., 2007. An exploratory study identifying the programme related stressors amongst qualified nurses completing part-time degree courses. Nurse Education Today 27, 731-738 Fortin, S., 2007. The online LIS Experience. Library Journal 58 Hollis, V., Madill, H., 2006. Online learning: the potential for occupational therapy education. Occupational Therapy International 13 (2), 61-78 Janes, G., 2006. Addressing the learning needs of multidisciplinary students at a distance using a virtual learning environment (VLE): a novice teacher reflects. Nurse Education in Practice 6, 87-97 Jarvis, P., 2005. Lifelong education and its relevance to nursing. Nurse Education Today 25, 655-660 EMPLOYER-BASED SUPPORT FOR REGISTERED NURSES UNDERTAKING POSTGRADUATE STUDY VIA DISTANCE EDUCATION 10 of 10 Kramer, M., Schmalenberg, C. E., 2005. Best quality patient care: A historical perspective on Magnet Hospitals. Nursing Administration Quarterly 29 (3), 275-287 Lawton, S., 1997. Supportive learning in distance education. Journal of Advanced Nursing 25, 1076-1083 Long, T., Johnson, M., 2002. Research in Nurse Education Today: Do we meet our aims and scope? Nurse Education Today 22, 85-93 McClure, M. L., 2005. Magnet Hospitals: Insights and issues. Nursing Administration Quarterly 29 (3), 198-201 Oehlkers, R.A., Gibson, C.C., 2001. Learner support experienced by RNs in a collaborative distance RN to BSN program. The Journal of Continuing Education in Nursing 32 (6), 266-273 Pelletier, D., Donoghue, J., Duffield, C., 2003. Australian nurses’ perceptions of the impact of their postgraduate studies on their patient care activities, Nurse Education Today 23, 434-442 Pelletier, D., Duffield, C., Adams, A., Nagy, S., Crisp, J., Mitten-Lewis, S., 2000. Australian nurse educators identify gaps in expert practice. The Journal of Continuing Education in Nursing 31 (5), 224-231 Polit, D. F., Beck, C. T. 2010. Essentials of Nursing Research: Appraising Evidence for Nursing Research. 7th ed. Lippincott, Williams & Wilkins, Philadelphia. Pym, R.R., 1992. Women and distance education: a nursing perspective. Journal of Advanced Nursing 17, 383-389 RCNA – see Royal College of Nursing Australia Royal College of Nursing Australia, 1998. Continuing professional development. Position statement, online, accessed 14 November 2008 Shovein, J., Huston, C., Fox, S., Damazo, B., 2005. Challenging traditional teaching and learning paradigms: online learning and emancipatory teaching. Nursing Education Perspectives 26 (6) 340-343. Simpson, R., 2007. Information technology: building nursing intellectual capital for the information age. Nursing Administration Quarterly 31 (1), 84-88 Wellard, S., Williams, A., Bethune, E., 2000. Staffing of undergraduate clinical learning programs in Australia. Nurse Education Today 20, 548-554 Westendorf, J. J., 2007. Recruitment and retention of current and future nurses. Plastic Surgical Nursing 27 (2), 93-97 Yonge, O.J., Anderson, M., Profetto-McGrath, J., Olson, J.K., Skillen, D.L., Bomen, J., Ratusz, A.R., Anderson, A., Slater, L., Day, R., 2005. An inventory of nursing education research. International Journal of Nursing Education Scholarship 2 (1), 1-11 Zalon, M., Meehan, T., 2005. Merging time zones: promoting international communication through videoconferencing. Nurse Education in Practice 5, 180-186