Evaluating the emergency nursing programme : views of the students

EVALUATING THE EMERGENCY NURSING PROGRAMME: VIEWS OF THE STUDENTS by PITSI ISABELLA MOTSEO 43736734 submitted in accordance with the requirements of the degree in MASTER OF ARTS in the subject HEALTH STUDIES at the UNIVERSITY OF SOUTH AFRICA PROMOTOR: Dr Tanya Heyns JOINT PROMOTER: Dr Isabel Coetzee September 2015  DEDICATION This dissertation is dedicated to my husband Kenneth, and my two lovely children, Prudence and Tshepho: they are all I am living for. It is also dedicated, in part, to my mother Phillistus Sithole for listening and supporting me when things were challenging. i  DECLARATION Student number: 43736734 I, Pitsi Isabella Motseo, declare that this research study entitled: EVALUATING THE EMERGENCY NURSING PROGRAMME: VIEWS OF THE STUDENTS is my own work and that all the resources consulted have been indicated and acknowledged by means of complete references. I further declare that this study has not been submitted for any other degree at any institution. Pitsi Isabella Motseo Date: 15 September 2015 ii  ACKNOWLEDGEMENT I am very much grateful for the almighty God who gave me strength and courage to complete this study. Thanks are also due to all the emergency nurses from the health institutions in the Limpopo province who were very useful in providing valuable information instrumental to making this study a success. I would also like to appreciate the following people for personally contributing to my success:  My supervisors, Dr Tanya Heyns and Dr Isabel Coetzee for supporting me throughout all the stages of the study.  My colleagues for their encouragement throughout the journey.  The Limpopo Department of Health and the Nursing Education institution for granting permission.  My husband and children for understanding and support.  Ms RC Langa for data collection and transcription of the data.  Professor K Masemola for editing my work. iii  ABSTRACT Background Trauma is the leading cause of death in the young (ages 1-44) and the current life situation is responsible for producing emergency injuries from motor vehicle accidents, violence and from acute life threatening illnesses. The training of emergency nurses is therefore of priority based on the increasing demands on the entire emergency health care system. The study evaluates the education and training of emergency nursing programme that has been offered for the past seven (7) years at a Nursing Education Institution (NEI) in the Limpopo province. The programme has not has not been formally evaluated. Aim The overall aim of the study is t o explore and describe the views of students pertaining to the emergency nursing programme offered at the NEI in the Limpopo province and to make recommendations for the refinement of the emergency nursing programme, based on the views of the nursing students. Methods A qualitative design working from an Appreciative Inquiry approach was employed. Purposive sampling was used and focus group interviews were conducted with 20 Professional nurses who are trained as emergency nurses at the NEI from 2007 to 2013. Two main themes emerged: theoretical aspects and clinical aspects, which included both positive and negative views. The findings were used to make recommendations to refine the programme. Key words: Appreciative Inquiry, trauma/ emergency nursing programme, evaluation, nursing student iv  TABLE OF CONTENTS Table of content Page Declaration I Dedication Ii Acknowledgements Iii Abstract Iv Table of content V List of reference Ix List of tables X List of figures Xi List of annexures Xii List of abbreviations Xiii CHAPTER 1: ORIENTATION TO THE STUDY 1.1 INTRODUCTION 1 1.2 BACKGROUND TO THE RESEARCH PROBLEM 3 1.2.1 Source of the research problem 3 1.2.2 Background to the research problem 4 1.3 RESEARCH PROBLEM 5 1.4 RESEARCH QUESTIONS 7 1.5 AIM OF THE STUDY 7 1.5.1 Research purpose 7 1.5.2 Research objectives 7 1.6 SIGNIFICANCE OF THE STUDY 8 1.7 DEFINITION OF KEY CONCEPTS 9 1.7.1 Evaluation 9 1.7.2 Nursing Education Institution 9 1.7.3 Nursing student 10 1.7.4 Emergency nursing programme 12 1.8 THEORETICAL FOUNDATION OF THE STUDY 11 1.8.1 Metatheoretical assumptions 11 1.8.1.1 Appreciative Inquiry assumptions 13 1.8.2 Theoretical framework 14 1.8.2.1 The 5-D cycle of Appreciative Inquiry 15 1.9 RESEARCH DESIGN AND METHODS 19 1.10 ETHICAL CONSIDERATIONS 21 1.11 SCOPE OF THE STUDY 22 1.12 STRUCTURE OF THE DISSERTATION 22 1.13 CONCLUSION 23 v CHAPTER 2: LITERATURE REVIEW 2.1 INTRODUCTION 24 2.2 PROGRAMME EVALUATION 24 2.3 DEFINING PROGRAMME EVALUATION 25 2.3.1 The purpose of evaluation 26 2.3.2 Types of evaluation 27 2.3.2.1 Evaluation of needs 27 2.3.2.2 Evaluation of process 28 2.3.2.3 Evaluation of outcome 28 2.3.2.4 Evaluation of impact 29 2.3.2.5 Evaluation of efficiency 29 2.3.2.6 Evaluability assessment 29 2.3.2.7 Utilisation evaluation 30 2.4 TRAUMA AND EMERGENCY TRAINING PROGRAMME 31 2.5 LEGISLATION INVOLVED IN PROGRAMME EVALUATION 32 2.6 APPRECIATIVE INQUIRY 33 2.6.1 History 34 2.6.2 Defining Appreciative Inquiry 35 2.6.3 Appreciative Inquiry approach versus problem solving approach 36 2.6.4 Principles 38 2.6.5 Appreciative Inquiry and positive change 40 2.7 EVALUATION METHOD 42 2.8 ADVANTAGES 46 2.9 CRITIQUE ON APPRECIATIVE INQUIRY 47 2.10 CONCLUSION 48 CHAPTER 3: RESEARCH DESIGN AND METHODS 3.1 INTRODUCTION 49 3.1.1 Setting 49 3.2 RESEARCH DESIGN 49 3.2.1 Characteristics of qualitative research 51 3.2.1.1 Natural setting 51 3.2.1.2 Researcher as the key instrument 51 3.2.1.3 Participants’ meaning 52 3.2.1.4 Holistic account 52 3.2.1.5 Emergent design 53 3.2.1.6 Inductive data analysis 53 3.2.1.7 Interpretative design 53 3.2.2 Explorative design 54 3.2.3 Descriptive design 54 3.3 RESEARCH METHODS 55 3.3.1 Sampling 56 3.3.1.1 Population 56 3.3.1.2 Inclusion criteria 57 3.3.1.3 Non-probability sampling 57 3.3.1.4 Ethical issues relating to sampling 59 3.3.1.5 Sample 60 3.3.2 Data collection 61 3.3.2.1 Focus group interviews 61 3.3.2.2 Field notes 64 3.3.2.3 Interview guide 65 3.3.2.4 Data collection process 66 3.3.2.5 Conduct Appreciative Inquiry interviews 67 vi 3.3.2.6 Ethical considerations related to data collection 70 3.3.3 Data analysis 73 3.3.3.1 Step 1: Get a sense of the whole 73 3.3.3.2 Step 2: Selection of a topic 74 3.3.3.3 Step 3: Cluster and compare the topics 74 3.3.3.4 Step 4: Review the data 74 3.3.3.5 Step 5: Refine the data 74 3.3.3.6 Step 6: Alphabetise the categories 74 3.3.3.7 Step 7: Preliminary analysis 74 3.3.3.8 Step 8: Recode existing data 75 3.4 TRUSTWORTHINESS 75 3.4.1 Credibility 75 3.4.1.1 Prolonged engagement 76 3.4.1.2 Data triangulation 76 3.4.1.3 Referential adequacy 76 3.4.1.4 Member checking 77 3.4.2 Transferability 77 3.4.2.1 Purposive sampling 77 3.4.2.2 Thick description 78 3.4.3 Dependability 78 3.4.4 Confirmability 78 3.4.5 Authenticity 79 3.5 CONTEXT 79 3.6 CONCLUSION 79 CHAPTER 4: ANALYSIS, PRESENTATION AND DESCRIPTION OF THE RESEARCH FINDINGS 4.1 INTRODUCTION 80 4.2 DATA MANAGEMENT AND ANALYSIS 80 4.2.1 Data management 80 4.2.2 Data analysis 81 4.3 RESEARCH RESULTS 81 4.3.1 Sample characteristics 81 4.3.2 Results 81 4.3.2.1 Theme 1: Expanding our knowledge and understanding 83 4.3.2.2 Theme 2: Delivering the practice in the clinical setting 109 4.4 OVERVIEW OF RESEARCH FINDINGS 136 4.4.1 Discover the ‘best of what is’ 136 4.4.2 Dream ‘what could be’ 136 4.4.3 Design ‘what should be’ 137 4.4 CONCLUSION 137 CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS 5.1 INTRODUCTION 138 5.2 RESEARCH DESIGN AND METHODS 138 5.3 SUMMARY AND INTERPRETATION OF RESEARCH 139 FINDINGS 5.3.1 Expanding our knowledge and understanding 139 5.3.1.1 Positive theoretical experiences 139 5.3.1.2 Shortages of resources 141 5.3.1.3 Orientation 142 vii 5.3.1.4 Acquisition of theoretical knowledge 142 5.3.1.5 Continuous professional development 143 5.3.1.6 Rules and regulations regarding training 144 5.3.2 Delivering the practice in the clinical setting 144 5.3.2.1 Positive clinical experiences 145 5.3.2.2 Negative clinical experiences 146 5.3.2.3 Clinical support 148 5.3.2.4 Clinical supervision 148 5.3.2.5 Acquisition of clinical skills 149 5.3.2.6 Students residential area 150 5.4 CONCLUSIONS 150 5.4.1 Expanding our knowledge and understanding 151 5.4.2 Delivering the practice in the clinical setting 151 5.5 RECOMMENDATIONS 152 5.5.1 Expanding our knowledge and understanding 153 5.5.2 Delivering the practice in the clinical setting 154 5.6 LIMITATIONS OF THE STUDY 155 5.7 CONCLUDING REMARKS 155 REFERENCE LIST 156 viii 1 2 List of tables Table 1.1 Intake and output profile 2007 – 2013: Emergency nursing programme 4 Table 1.2 Appreciative Inquiry assumptions 13 Table 1.3 Summary of the research methods 21 Table 1.4 Structure of the dissertation 22 Table 2.1 Comparison of problem solving and Appreciative Inquiry process 38 Table 2.2 Summary of principles of Appreciative Inquiry 39 Table 2.3 Comparison of programme evaluation process and Appreciative Inquiry 44 Table 4.1 Summary of themes, categories and sub-categories 82 3 List of figures Figure 1.1 The 5-D Model of Appreciative Inquiry 17 ix 3.1.1.1List of annexures Annexure A Ethical approval to conduct the research A.1 UNISA A.2 Limpopo Department of Health A.3 Limpopo College of Nursing A.4 Application for permission to conduct the study Annexure B Participant information leaflet Annexure C Appreciative interview guide Annexure D Declaration by transcriber Annexure E Example of transcription Annexure F Declaration by editor x 3.1.1.2List of abbreviations AI Appreciative Inquiry NEI Nursing Education Institution SANC South African Nursing Council For the purpose of anonymity, the hospital in which the study was conducted will be referred to as the hospital, in both text and referencing. xi  Orientation to the study 2016 CHAPTER 1: ORIENTATION TO THE STUDY 1.1 INTRODUCTION Trauma is the leading cause of death in the young (ages 1-44) in the United States and the chief reason for the lost years of productive life among citizens living in industrialized countries besides illnesses (McQuillan, Makic & Whalen 2009:10; Cameron 2015:71; Urden, Stacy & Lough 2014:849). Nurses have long been challenged by the complexity of the health care needs of the seriously ill/injured patients and their families. The current life situation is responsible for producing emergency injuries from motor vehicle accidents, violence and from acute life threatening illnesses (McQuillan et al 2009:10). The evolution of the specialty field of emergency nursing in the health care arena emanated from a response to the changes in which the frequencies of emergency incidences occur, the magnitude and severity of injuries, the complexity of the therapeutic needs of the emergency patient population and, ultimately, the increasing demands on the entire health care system (McQuillan et al 2009:10). Emergency nurses are the primary health care providers to come in contact with patients based on their availability 24 hours around the clock in all health care facilities in South Africa. In responding to a situation presented by a patient as an emergency, the emergency nurse has to utilise a range of technical, intuitive and personal knowledge in deciding how to best manage the patient, therefore adequate emergency care nurse training is of priority in the management of these patients (Jones, Endacott & Crouch 2007:2; DeCola, Benton, Peterson & Matebeni 2012:2). The development of advanced medical interventions and technology resulted in the increasing recognition that nurses play in the role of monitoring and management of critically ill patients (Urden, Stacy & Lough 2010:1). Physicians depend on nurses as they are available for patients around the clock to monitor for critical changes in the condition of patients and manage the critically ill patients in the physicians’ absence (Urden, Stacy & Lough 2010:3). Emergency nurses play a vital role in sorting patients according to the priority of injury/illnesses and apply assessment techniques 1  Orientation to the study 2016 in the emergency management of critically ill and injured patients using advanced physiologic monitoring technologies and diagnostic procedures. Therefore the need for quality education and training is alarmingly increasing (McQuillan et al 2009:11). The regulation of nursing practice in South Africa is done through the Nursing Act No.33 of 2005. The South African government has, through the Nursing Act No.33 of 2005, delegated the responsibility for the promotion and maintenance of standards in nursing education to the South African Nursing Council (SANC). The SANC serves as the accrediting body of the training facilities, as well as monitoring the process of nursing education to ensure that nurses offer quality nursing care within the provisions of the Constitution of the Republic of South Africa. The Critical care Nursing: Trauma nursing speciality, like all other nursing fields is affected by the state laws that define the minimum standards required of a licensed nurse to protect citizens from untrained or incompetent persons offering nursing practice. The SANC teaching guide which delineates the requirements for the diploma in Emergency Nursing as a programme in clinical nursing science leading to registration of an additional qualification is stipulated in SANC regulation (Regulation 212 of 1993 as amended by Regulation 74 of 1997). The South African Qualifications Authority Act No.58 of 1995, in terms of which the Nursing Council is accredited as an Education and Training Quality Assurance body (ETQA) for nursing practice, is charged with the quality assurance of nursing education and training providers, courses and / unit standards. Other important authorities include the National Qualifications Framework (NQF) and the South African Qualifications Authority (SAQA) who has to register all higher education qualifications (Searle, Human & Mogotlane 2011:351). Nursing education institutions are accredited for training. These strive towards improved education and training of nurses to meet the quality education standard as expected by the regulating bodies. It is the nursing education institutions that are responsible for ensuring quality education and training by conducting annual self-assessment for effectiveness as determined by the monitoring and evaluation standards by the SANC (Nursing Act No.33 of 2005 (17(1):14). 2  Orientation to the study 2016 The accredited SANC Emergency nursing programme was initiated in Limpopo province in 2005 in partnership with a specific private nursing education institution (NEI) in Gauteng Province. The NEI in Limpopo province commenced education and training of the emergency nursing programme in 2008.There are four health care institutions that are accredited by SANC for education and training of the emergency nursing programme. The vision of the NEI in Limpopo is described in the Northern Province College of Nursing Act No. 3 of 1996: as “A Centre of excellence in nurse training and education and the mission as: committed to facilitate community and outcome based, quality, scientific nursing education and training that is sensitive to human rights in a multi-sectoral environment”. The researcher is currently a nurse educator involved with the education and training of professional nurses for emergency nursing programme as an additional qualification at a nursing education institution in the Limpopo Province. The Emergency nursing students’ experiences of the programme are currently evaluated informally through an evaluation survey that is done collectively in collaboration with learners enrolled for all the other specialties in the medical and surgical nursing programmes at the end of each academic year. The identified challenge is that the recommendations are based on the evaluation results which are generalized for all the programmes and not specific to the emergency nursing programme. The emergency nursing programme has been offered for the past seven (7) years at this NEI. The fact that the programme was not yet formally evaluated as an individual specialty prompted the need for formal evaluation process to enable the nurse educators to refine the emergency programme, with the aim of improving the quality of education and training. 1.2 BACKGROUND TO THE RESEARCH PROBLEM The following discussion gives an overview of the background to the research problem. 3  Orientation to the study 2016 1.2.1 Source of the research problem According to statistics South Africa (2014:43) Limpopo province is amongst the leading provinces with increased number of transport accidents. It therefore requires more nurse practitioners specialised in emergency nursing care. The general shortage of emergency nurses around South Africa poses a challenge for education and training of nurses in emergency nursing to meet the needs for increasing number of patients in the emergency units across the country. Emergency nurses can play a pivotal role in the delivery of emergency health care at pre-hospital environments and within the health care institutions to decrease the mortality and morbidity rate of the critically ill /injured patients (McQuillan et al 2009:5). The Emergency nursing programme was initially offered in other provinces in South Africa before the Limpopo province was accredited for training in 2005. Students admitted to the emergency nursing programme are allocated in clinical areas at the four accredited institutions in the Limpopo province to acquire the necessary clinical skills relevant to the expected theory. The programme is offered for the duration of 12 months full-time study. The students are required to comply with the required hours in theory which is 80 hours per subject (80 x 3 =360) and 1000 hours for clinical practice as regulated by SANC Regulation 212 of 1993 as amended by Regulation 74 of 1997. Since the inception of the programme, the success rate in completion of the programme ranges from 50-63% (see Table 1.1.) Table 1.1: Intake and output profile 2007-2013: Emergency nursing programme No. of students completed at Year No. of students enrolled Pass rate record time 2007 9 5 56% 2008 12 6 50% 2009 16 11 69% 2010 17 12 71% 2011 19 11 58% 2012 21 16 76% 2013 9 7 78% Overall 103 68 65% average 4  Orientation to the study 2016 As reflected in Table 1.1., the intake and output profile from 2007 to 2013 indicates a pass rate ranging from 50% to 78%. 1.2.2 Background to the research problem Education and training in the emergency nursing programme requires successful completion of the theoretical and clinical component by students enrolled for the programme. The researcher is currently involved as a nurse educator offering the programme. The students enrolled for the programme at the specific NEI in the Limpopo Province often verbalise some of the challenges they meet during education and training in their contact sessions. This prompted the researcher to acknowledge the urgent need to formally evaluate the programme. The following are some of the challenges that were verbalised by the students: Supportive quotations by students. Theoretical component “…there is too much theory included for the programme…” “…the programme is too difficult…” “…the duration of the programme is short as compared to the workload…”. Supportive quotations by students. Clinical component “…Some of the clinical skills to be learned are difficult to complete due to timing related to patients’ availability…” “…the clinical skills require dedication to complete…” “..there is inadequate accompaniment by the nurse educators…” It is imperative for the researcher to include both theoretical and clinical aspects when evaluating the programme for a comprehensive quality profile. The Appreciative Inquiry process will be utilized as a positive evaluation approach to gain information from perspective of the professional nurses who completed the emergency nursing programme at the NEI in the Limpopo Province. Evaluating the programme will yield positive responses and allow the participants an opportunity to 5  Orientation to the study 2016 reflect critically on their experiences as post-basic students following completion of training in emergency nursing. The formal evaluation of the programme by the nursing education institution is not yet done. The programme is being offered although there are a variety of available trauma training programmes also offered by the department of health which are medically led and emphasis is placed on pre-hospital care in the field and critical care in intensive care units. Such programmes include; Basic Life support (BLS), Advanced Trauma life support (ATLS), Advanced Pediatric life support (APLS), Advanced Cardiac life support (ACLS) and Advanced Medical life support (AMLS).The expanding body of knowledge in emergency nursing programme involves pre-hospital, care of both injured and medical emergencies of all ages in the emergency unit, critical care units and rehabilitation areas so as to manage the patient within the holistic perspective of an individual. 1.3 RESEARCH PROBLEM According to Welman, Kruger and Mitchell (2012:13), the research problem refers to some difficulties that the researcher experiences in the context of either a theoretical or practical situation and to which the researcher wants to obtain a solution. Burns and Grove (2011:146) define the research problem as an area of concern where there is a gap in the knowledge base needed for nursing practice. Polit and Beck (2012:73) explain research problem as an enigmatic, identified difficulty or trouble shooting condition that requires a solution. The researcher as the nurse educator involved in the education and training of emergency nursing programme realized that a formal evaluation of the programme was not conducted for the past seven (7) years. The students often verbalise specific challenges pertaining to the theoretical and clinical aspects in the education and training of the emergency nursing programme offered by the NEI. The nursing education institution has the responsibility to do self-evaluation as required by the South African Nursing Council, in order to ensure quality education and training. Based on the feedback from informal inquiries from the students and for quality 6  Orientation to the study 2016 assurance, the researcher realized that the formal evaluation of the theoretical and practical component of the emergency nursing programme was relevant to deal with challenges that might be identified from the evaluation process to refine the programme. 1.4 RESEARCH QUESTION Brink, van der Walt and van Rensburg (2011:86) define research questions as those interrogative statements or questions which yield facts to solve a problem, generate new research, add to theory or improve health care. Research question is further explained by Polit and Beck (2012:73) as the specific queries that researchers want to answer in addressing the research problem. A research question is a concise, interrogative statement that is worded in the present tense and includes one or two variables or concepts to direct the conduct of the study (Burns & Grove 2011:163). In view of the background to the study and the problem statement, the study aims to answer the following research question: What are the views of students pertaining to the of emergency nursing programme offered at a nursing education institution in the Limpopo Province? 1.5 AIM OF THE STUDY The overall aim of the study is t o explore and describe the views of students pertaining to the emergency nursing programme offered at the NEI in the Limpopo province, and to make recommendations for the refinement of the emergency nursing programme, based on the views of the nursing students. 1.5.1 Research objectives The objectives of the study are as follows: 7  Orientation to the study 2016  Explore and describe the views of post-basic students pertaining to the theoretical component of the emergency nursing programme.  Explore and describe the views of post-basic students pertaining to the clinical component of the emergency nursing programme.  Suggest recommendations for the refinement of the theoretical of the emergency nursing programme.  Suggest recommendations for the refinement of the clinical component of the emergency nursing programme. 1.6 SIGNIFICANCE OF THE STUDY The evaluation of the emergency nursing programme will be significant to the nursing education institution, the students, nursing practice, and to the community to whom the service is provided. To the nursing education institution will benefit from the evaluation as it could:  Provide guidelines for the refinement of the theory and practical component in the education and training that constitute the core of emergency nursing programme .  Increase the NEI’s accountability and responsibility for the quality of training they render and commitment to a reliable and productive work.  Be a valuable mechanism for strengthening quality assurance practice within the NEI by ensuring that formal biannual programme evaluation is done. For the students:  The students are provided the opportunity to give inputs pertaining to the theoretical and clinical component of the programme.  Programme evaluation will aid in ensuring that students receive quality education and training that will improve skills, knowledge and attitudes. 8  Orientation to the study 2016 Nursing practice will benefit due to:  The clinical component of the programme that can be refined based on the findings of the study.  Programme evaluation can assist in enhancing skilled and knowledgeable nurse practitioners in the clinical practice. For the community:  The refined programme will increase the quality of education and training and, in turn, increase the quality of health care rendered to the patients in the community. 1.7 DEFINITION OF KEY CONCEPTS The following concepts are given to provide an understanding of their application in this study. 1.7.1 Evaluation Evaluation is defined as a systematic, rigorous, and meticulous application of scientific methods or processes to assess the design, implementation, improvement, impact or outcomes of a programme (Rossi, Lipsey & Freeman 2004:28; Bless, Higson-Smith & Sithole 2013:113). The authors further explain that the process frequently requires resources, such as evaluator expertise, labour, time and a sizeable budget. Preskill and Catsambas (2006:37) explain evaluation as a process for enhancing knowledge and decision-making, whether the decisions are related to improving or refining a program, process, product, system, or organisation or to determining whether or not to continue or expand a programme. In addition, Mcmillan and Schumacher (2010:430) state that in each of these decisions, there is some aspect of judgment applied about the evaluand’s merit, worth, or value. Taking this further, Potter (2006:410) defines evaluation as a systematic method for collecting, analyzing, and using information to answer questions about projects, policies and programmes, particularly about their effectiveness and efficiency. 9  Orientation to the study 2016 For the purpose of this study, evaluation means a systematic process of exploring and describing the experiences and lessons learned by stakeholders (professional nurses trained in emergency nursing), for utilization in refinement of current theoretical and clinical activities in the emergency nursing programme to improve future training. 1.7.2 Nursing education institution A Nursing Education Institution (NEI) is an institution, organisation, college or any other higher education institution accredited for the conducting of educational programmes to prepare persons for the practice of nursing in terms of the Nursing Act No 33 of 2005 (Armstrong, Geyer, Mgomezulu, Potgieter & Subedar 2011:116). It is, strictly speaking, an institution where the formal training and education of nurses takes place to ensure competent and ethical practice in nursing (Searle, Human & Mogotlane 2011:342). The Government notice (No. R1045 of 2011:3) refers to a nursing education institution as a type of founded establishment or organization consisting of buildings and its associated resources for the specific purpose of offering nursing education and training programmes as approved by the South African Nursing Council in terms of section 15(2) of the Nursing Act No 33 of 2005. For the purpose of this study, a nursing education institution refers to an organisation accredited by SANC for the training in respect of the emergency nursing programme in the Limpopo Province. 1.7.3 Nursing student A nursing student refers to a student who has been formally accepted into a nursing programme; regardless of whether they have taken any nursing courses (Fikelman & Kenner 2013:115). According to Armstrong, Geyer, Mgomezulu, Potgieter and Subedar (2011:187), a nursing student is any person who enters the basic nursing education programme after successfully completing schooling and meets the entrance requirements for higher education at an approved school (college) of 10  Orientation to the study 2016 nursing. Accordingly, the Department of Health nursing strategy for South Africa (2008:5) defines a nursing student as a person undergoing education or training in basic or post-basic nurse training. For the purpose of this study, a nursing student refers to professional nurses already trained with a nursing education institution in the Limpopo province for the specialised theory and related clinical practice relevant to the field of emergency nursing. 1.7.4 Trauma/Emergency nursing programme Emergency nursing is an independent and collaborative specialised area of practice that delivers urgent and complex care to health care consumers with a variety of illnesses and injuries across the lifespan in a variety of settings (Emergency Nurses Association 2011:1). In the same vein, Jones et al (2007:2) describe emergency nursing programme as an embracing art, science, ethics and use of self in responding to a situation presented by the patient as an emergency. The authors further state that the utilization of technical, intuitive and personal knowledge is required to make decisions on how to best manage the patient in response to each situation as it is presented. In more specific terms, Sheehy (2007:560) describes emergency nursing as care provided to individuals of all ages with perceived or actual physical or emotional alterations of health that are undiagnosed or that require further interventions. According to SANC, Emergency nursing programme is a course in clinical nursing science leading to the registration of an additional qualification as stipulated in SANC regulation (Regulation 212 of 1993 as amended by Regulation 74 of 1997). For this study, emergency nursing programme refers to the critical care nursing: trauma programme offered by a nursing education institution in the Limpopo province as accredited by the SANC (Nursing Act No 33 of 2005 2(1):4). 11  Orientation to the study 2016 1.8 THEORETICAL FOUNDATIONS OF THE STUDY The foundations of the study are based on the meta-theoretical assumptions that reflect the nature of the study and the theoretical framework on which the study is based. 1.8.1 Meta-theoretical assumptions Meta-theoretical assumptions refer to the researcher’s beliefs about the person as a human being, society, the discipline and the purpose of the discipline as well as the philosophical orientation about the world and the theoretical underpinnings on which the studies are grounded (Botma, Greeff, Mulaudzi & Wright 2010:187). According to Babbie and Mouton (2011:20) and Burns and Grove (2009:40), meta-theory refers to critical reflection on the nature of scientific inquiry which includes the structure of the scientific theory, the nature of scientific growth, the meaning of truth, explanation and objectivity of the inquiry. In like manner, meta-theoretical assumptions are regarded by Henning, van Rensburg and Smith (2004:15) as interrelated sets of concepts, beliefs, commitments and propositions that constitute the study. These assumptions are often characterized in terms of the ways in which they respond to basic philosophical questions: the epistemological, ontological and methodological assumptions. Epistemology is intimately related to ontology and methodology. Ontology involves the nature of reality and its characteristics (Creswell 2007:16). The ontological reality in this study is related to the multiple realities described by the participants on practice in the Emergency nursing programme which include the students’ views on the practice by the NEI for students to acquire expected theoretical knowledge and clinical practice skills to care for the injured and critically ill patients. The collected data from the students was coded and grouped into themes to yield meaning. Epistemology addresses how the researcher comes to know the reality about the programme (Creswell 2007:18). An independent facilitator was utilized in the process of inquiry. The information regarding the views of the students on the programme was shared through Appreciative Inquiry (AI) focus group interviews. Methodology refers to the principles and ideas on which the researchers base their procedures 12  Orientation to the study 2016 and strategies (Holloway & Wheeler 2010:21). In this study the process of inquiry followed the 5-D process of Appreciative Inquiry (AI) where inquiries are based first on the positive aspects so that the negative perspectives are easily dealt with. The assumptions and principles guiding the study, the meaning and application in this study are based on the interpretive paradigm of Appreciative Inquiry (AI) as described by Sue Hammond (1998:20).The meaning and application of AI assumptions will be described in the section that follows hereunder. 1.8.1.1 Appreciative inquiry assumptions Polit and Beck (2012:748) define assumptions as principles that are accepted as being true based on logic or reason, without proof. Assumptions are the principles translated into clarifying statements that explicitly state the position of the researcher in the context to facilitate the process (Reed 2007:27). The assumptions behind AI are stated as a definitive result of the history and development of the discipline and are made easier to communicate (Reed 2007:29). The description of assumptions underlying AI provides the basis from which AI begins. Table 1.2: Appreciative Inquiry assumptions Assumption Meaning Application In every society, organisation By drawing attention to what the Through appreciative inquiry or group, something works. people feel has been achieved, the positive aspects from shared reality they experience is one in experiences on the programme which things can be done well were identified and acknowledged. What we focus on becomes What people focus on as the topic The focus of the inquiry during the our reality. of inquiry, becomes the reality of AI interview process with the the current practice. stakeholders (Emergency trained professional nurses) will draw attention to achievements that were made and in this way a reality of “what should be”, of the programme can be experienced. Reality is created in the The assumption is built on the Reality was created during the moment, and there are poetic principle, of drawing moment when stakeholders share multiple realities. attention to the way appreciative their experiences and views about inquiry can move to exploring the the programme. story-authoring process and work with multiple realities ,rather than spending time searching for a single ‘truthful’ account in which the facts can be checked and verified. 13  Orientation to the study 2016 Assumption Meaning Application The act of asking questions of The words chosen for, asking The direction of questions an organisation, or group questions directly influences the influenced the way stakeholders influences the group in some dynamics of the conversations and reflected on the programme, their way. gets people to think on their understanding, perception and activities in new ways. This new created innovative thoughts on the way of thinking can lead to new future of the programme ways of doing. This assumption is linked to the principle of simultaneity. People have more confidence Exploring and building on current Appreciation of the past to journey to the future (the acts, gives people the confidence to experiences created confidence and unknown) when they carry go forward: confidence reaffirms comfort in the formation of a firm forward parts of the past (the their worth, ability and potential. foundation to carry forward what the known). stakeholders wish the programme “could be”. It is important to value Reflects the importance of different Differences related to the meaning, differences. views and perspectives, which nature of understanding and needs to be appreciated. interpretations by stakeholders will be carried forward with pride for future outcomes of the programme. The language we use creates Draws on ideas from social The positive language that was our reality. constructionist thought, which used created positive changes on emphasizes the importance of the intentions for the future language in the process of programme. constructing reality. Adopted from Sue Hammond 1998:20-21 1.8.2 Theoretical framework A theoretical framework is defined by Polit and Beck (2012:126) as the overall conceptual underpinnings of a study. It follows that a theoretical framework of a research study helps in organizing the study with regard to a context in which a research problem is examined, data gathering and analysis based on propositional statements from an existing theory (Brink, van der Walt & van Rensburg 2012:26). The Appreciative Inquiry (AI) process was utilized for evaluating the programme. AI is “a process that inquiries into, identifies, and further develops the best of what is in organisations in order to create a better future” (Coughlan, Preskill & Catsambas 2003:5). Appreciation is described by Cooperrider, Whitney and Stavros (2003:29) as a means to value, recognizing the best in people or the world around the people, affirm past and present strengths, success, and potentials, to perceive those things that give life to living systems. AI involves systematic discovery of what gives life to a programme when it is most effective (Cooperrider & Whitney 2005: 8). According to Ashford and Patkar (2001:4), the Appreciative Inquiry improves organisations more 14  Orientation to the study 2016 effectively through discovery and valuing, envisioning, dialogue and constructing the future. In this study the choice of the Appreciative Inquiry approach was motivated by the way with which qualitative research and evaluation are integrated within its theoretical framework. The researcher was able to appreciate the positive aspects of the programme during the process of evaluation based on the assumptions of appreciative inquiry that guided the study.The present format of inquiry followed the 5-D Cycle of the Appreciative inquiry process to gather information. 1.8.2.1 The 5-D cycle of appreciative inquiry Cooperrider and Whitney (2005:16) explain appreciative inquiry 5-D cycle as an activity that starts by engaging the stakeholders in the programme in a broad set of interviews and deep dialogue about the strengths, resources and capabilities. The process and future of an Appreciative inquiry is centred on the positive core strengths of the organisation or programme. Cooperrider, Whitney and Stavros (2008:34) state that the concept of the positive core is separate from yet central to the 5-D cycle. The 5-D cycle of appreciative inquiry was utilized in this study to guide the format of questions during focus group interviews. The 5-D cycle involves phases that include definition, discovery, dream, design and destiny (Watkins & Mohr 2001:25). The five phases incorporate the positive core as a foundation for positive change within a programme, “Definition of the topic, “Discover” what is, “Dream” what could be, “Design” what should be and “Destiny” as illustrated in Figure 1.1. The 5-D Cycle will be briefly discussed. 1.8.2.1.1 Positive core Cooperrider et al (2008:34) further state that human systems grow in the direction of their persistent inquiries and the idea is sustained when the means and ends of the inquiry are correlated in a positive way. The authors are of the opinion that the 5-D cycle is a mechanism that allows the researchers to access and mobilise the positive core and in this way the programmes’ positive core becomes the beginning and the end of the inquiry. 15  Orientation to the study 2016 In line with the above, Cooperrider et al (2008:34) further postulate that the positive core is woven through the phases of the 5-D cycle. In the definition and discovery phase a positive inquiry process is initiated and mobilised, to identify that which gives meaning to the programme or organisation. The positive core is further amplified through the Dream phase where clear results-orientated visions are created. During the Design phase, provocative prepositions for the ideal programme or organisation are created and finally implemented throughout the Destiny phase where the capability and positive potential of the organisation is strengthened. In the context of this study the positive core evolved around the programme evaluation based on the positive approach in Appreciative Inquiry. 1.8.2.1.2 Define the challenge The phase involves designing what the focus of the study is and creating the inquiry process. Appreciative inquiry is a process for engaging all relevant and interested people in positive change (Cooperrider et al 2008:101). It is with view of Whitney and Trostenbloom (2003:134) that people and groups move in the direction of what they study. The focus of inquiry emanated from the inception of a programme in the education and training for an additional qualification, as stated previously in the background and source of the problem in section 1.2.1. The appreciative nature of inquiry was developed in this phase through positive questions. The inquiry process about the education and training of the emergency nursing programme is based on the information elicited by the professional nurses trained in the nursing education institution in the Limpopo province from 2007 to 2013. 16  Orientation to the study 2016 POSITIVE CORE CORE C Figure 1.1: The 5-D Model of Appreciative inquiry (adopted from Kimberly Seitz 2009:73) 1.8.2.1.3 Discover “what is?” The Discovery phase is about asking questions that discovers what is best in the programme (Reed 2007:28). The discovery of what to uncover, learn and appreciation of “what is” and “what has been” (Whitney and Trosten-Bloom 2003:7) is unveiled in this phase. Furthermore, Cooperrider, Whitney and Stavros (2008:104) are of the opinion that when interviews are conducted, stories are shared and common themes are identified that cuts across the many stories and high point experiences and successes. In this study the researcher discovered the reality about the programme from the positive experiences that were shared by the participants. 17  Orientation to the study 2016 1.8.2.1.4 Dream “what could be?” The dream phase involves “the creation of a vision that brings to light the collective aspirations of stakeholders” that emerged in the discovery stage (Sullivan 2004:224).In addition Whitney and Trosten-Bloom (2003:179) states that in this phase the stakeholders are engaged in a process to envision the future of the programme, that is discussing what they learned in “Discovery’ and then imagine a more inspiring, positive, life giving world in the programme. Cooperrider, Whitney and Stavros (2008:130) state that during this phase the stakeholders are encouraged to talk about “what could be” a better programme. The dreaming phase involves unlimited, creative big thinking about future plans based on the positive discoveries (Reed 2007:33). In the context of the study, the focus of the stakeholders was based on the best of what the Emergency nursing programme could be. The focus in this phase was for the stakeholders to imagine what could be possible within the programme to make it a success. The stakeholders are encouraged on envisioning and valuing the best possible future programme. 1.8.2.1.5 Design “what should be?” Preskill and Catsambas (2006:20) describe the phase as a step where stakeholders learn from their successful experiences and associate them with their dream to discover new ways to create what should be. Reed (2007:33) further explains that, in this phase the stakeholders work together to craft plans for the future which involves creating provocative propositions that act as challenging value statements for empowerment. In the context of this study the phase involves drawing together of common themes from the stakeholders views, making recommendations in order to create provocative propositions that act as challenging value statements for empowerment and refining the programme. 18  Orientation to the study 2016 1.8.2.1.6 Destiny, “what will be?” Whitney and Trostem-Bloom (2003:220) refers to the destiny phase as the time for consideration of how the “creative ways about the ideal programme might be actualized”. The destiny phase represents taking action on the provocative propositions. In view of Preskill and Catsambas (2006:25), the destiny phase involves a process of thinking about specific activities, actions and making commitments to tasks and processes. Cooperrider and Avital (2004:143) speculate that focusing on envisioning positive possibilities through the articulation of organisational design ideals opens the way for sustainable change. In the context of this study, the designed action plan will be presented to the college management of the specific Nursing Education institution in the Limpopo Province and identified responsible groups tasked with the realisation and operationalisation of the action plan to refine Emergency programme. 1.9 RESEARCH DESIGN AND METHODS A research design is a plan that explains the how, when and where data is to be collected and analysed (Polit & Beck 2012:58), the researcher chooses the most appropriate design to meet the aims and objectives of the study (Parahoo 2006:183). In addition, Babbie and Mouton (2011:72) refer to research design as a plan of scientific inquiry to be followed on conducting a study. Burns and Grove (2011:547) define research design is a blueprint for conducting a study that guides the planning and implementation of the study in a way that will most likely achieve the intended goal. Polit and Beck (2012:741) further purport that the method or techniques used to gather and analyze information in research are done in a systematic fashion, and include the entire strategy for the study from the beginning to the end. The goal of the study was to rely as much as possible on the participants’ experiences involving the emergency programme. The researchers’ intent in this study is to interpret the meanings the participants have about the programme using descriptive qualitative research approach. Considering the above, qualitative 19  Orientation to the study 2016 descriptive research approach was chosen for this study because it is systematic and realistic in capturing people’s experiences. A qualitative research design is described by Babbie and Mouton (2011:270) as naturalistic methods of inquiry that attempt to deal with the issue of humans by exploring them directly with the aim of having in-depth descriptions and understanding of social actions. It is with in mind, considered together with the view of Bless, Higson-Smith and Sithole (2013:16) that the researcher in qualitative approach investigates a problem from the participants’ point of view to determine what the participants think and feel about a particular phenomenon. Furthermore, Speziale and Carpenter (2007:21) argue that in qualitative research, multiple realities occur as individuals participate in social actions based on previous experience understanding reality in a different way, thus multiple realities are to be considered to fully understand the reality in the programme. The participants in this study were free to express their views and experiences about the theoretical and the clinical component of the programme. The qualitative approaches allow the researcher to explore the depth, richness and complexity of the programme as experienced. A descriptive study is best suited for this study as the research is giving a descriptive account of the participants’ experiences on the education and training in the Critical Care Nursing: Emergency programme. Research methods are described by Polit and Beck (2012:12) as the techniques used to structure a study, gather and analyze information in a systematic way. The research methods used in this study indicated in Table: 1.3. 20  Orientation to the study 2016 Table 1.3: Summary of the research methods Population Sampling Sample Data collection Data analysis Trustworthiness Emergency Non- 20 Focus group Teschs’ Strategies used: care nurses probability – Emergency discussions. method of data Credibility who purposive care nurses Field notes analysis Dependability completed the Appreciative Confirmability (Section 3.3.2.) programme in Inquiry Interview Transferability a NEI in the guide (Section 3.8.) Limpopo (Annexure: D) Province (Section 3.3.1.) Table 1.3 summarises the research methods used in the study. These included population, sampling, sample, data collection and analysis as well as methods for establishment of trustworthiness. The details of the research design and methods used to guide the study are thoroughly explained in Chapter 3. 1.10 ETHICAL CONSIDERATIONS Ethical principles that need to be considered in research include the following: the principle of respect for persons, the principle of beneficence and, the principle of justice (Brink et al 2012:34). Protecting human rights is an important part of nursing research, and this is included in the principle of respect for persons. Respect for human rights involves the right to self-determination, the right to privacy, the right to autonomy and confidentiality, the right to fair treatment and the right for protection from discomfort and harm (Burns &Grove 2011:110).The proposal was first reviewed by the research ethical committee of the faculty of health sciences of the university (Annexure: A ), the ethical committee of the Department of Health Limpopo province (Annexure: B ),and the Nursing Education Institution (Annexure: C ), to protect the ethical rights of the participants. An in-depth discussion of the ethical consideration follows in Chapter 3 (View section 3.3.2.5). 21  Orientation to the study 2016 1.11 SCOPE OF THE STUDY “Scope” refers to the degree to which the findings of a study can be generalized to other settings (Van Eden & Terreblanche 2000:135).This study’s aim is to provide accurate information on the theoretical and clinical component of the emergency nursing programme as evaluated through the participants’ views for interpretation to give true valuable meaning that will help refine the programme to improve the quality of education and training. 1.12 STRUCTURE OF THE DISSERTATION The structure of the dissertation is presented in Table 1.4. Table 1.4: Structure of the dissertation Chapter Title Description Chapter 1 Orientation to the study The chapter presents the orientation to the entire study. It includes the background information about the research study, the aim of the study, the significance, the foundations of the study with specific reference to Appreciative inquiry, the research design, the methods employed for data collection and analysis, ethical considerations, the scope of the study and the structure of the dissertation. Chapter 2 Literature review This chapter focuses on programme evaluation and appreciative inquiry as applied in this study. Chapter 3 Research design and method The chapter describes the research design, methodology with specific reference to Appreciative Inquiry as a data collection process, the method used for analyzing data and strategies that were followed to ensure trustworthiness Chapter 4 Analysis, presentation and The chapter gives an in-depth overview of the analysed description of the research data and the description of the findings of the study findings supported by literature control. Chapter 5 Conclusions and The chapter presents the conclusion drawn from the recommendations research findings and recommendations that were made to refine the programme. 22  Orientation to the study 2016 1.13 CONCLUSION The demand for education and training of emergency nurses is increasing, based on the increasing number of patients that require emergency care. This greatly impacts on the morbidity and mortality of the patients managed in emergency and critical care units. Therefore, nurses need to be equipped with adequate theoretical knowledge and skills to improve the quality of emergency care practice. The aim of the study was to explore and describe the theoretical and clinical component of the emergency programme utilizing the views of professional nurses who completed the programme. Because healthcare is a fast changing field, the programme needs to be evaluated on a regular basis, further to identify challenges that require adjustment to meet both the educational needs of the students and health needs of the community. Chapter 2 will provide detailed information on Appreciative Inquiry as applied in programme evaluation. 23  Literature review 2016 CHAPTER 2: LITERATURE REVIEW 2.1 INTRODUCTION In Chapter 1 an overview to the study was provided. In this Chapter programme evaluation and the theoretical background on Appreciative inquiry (AI) will be explained. The purpose, types of evaluation and applicable legislation to be followed on evaluating a programme is outlined. The theoretical background of Appreciative Inquiry philosophy is important to understand the origin and implications for the application of this theory in evaluation of the programme. The assumptions and principles of Appreciative Inquiry are explained for the purpose of guiding on the application of Appreciative Inquiry process in evaluating a programme. 2.2 PROGRAMME EVALUATION Programme evaluation is a systematic evaluation research which is relatively modern in the 20th century in the United States of America (Rossi, Lipsey & Freeman 2004:8). It is further stated by Patton (2002:147) that its modern beginning has its traces in the 1900s with the work of Thorndike and colleagues in the educational testing where assessment of literacy and occupational training programmes and public health initiatives were highly valuable prior to the first World War, with the aim of reducing mortality and controlling the spread of infectious diseases. According to Patton (2002:147) as supported by Karamn, Kucuk and Aydemir (2013:836) programme evaluation was initially focused on measuring attainment of goals and objectives to find out whether the programme was working well. Potter and Kruger (2001) in Terre Blanche and Durrheim (2010:411) view programme evaluation as a process that draws on many different theories of social development to focus on theories of change that directly deals with social programmes so as to analyse the way in which the programmes are working, challenges that were met during implementation and how they were solved. The authors further state that the central goal of programme evaluation is focused on 24  Literature review 2016 answering specific practical questions related to the development and process of the programme. These questions are normally on how a programme is implemented, the outcome as well as the quality of the service or training provided. Studies that evaluate quality may be conducted from an internal perspective by someone working within the programme. They may be also carried out within an institution or even from an external perspective (Bless, Higson-Smith & Sithole 2013:113). 2.3 DEFINING PROGRAMME EVALUATION Programme evaluation is described by Babbie and Mouton (2011:335) as the use of social research methods to systematically investigate the effectiveness of social interventions within a programme. The authors mentions programme evaluation as techniques that draw on the concepts of social science disciplines that are intended to be useful for improving a programme. Chen (2005:3) defines programme evaluation as “the application of evaluation approaches, techniques and knowledge to systematically assess and improve the planning, implementation and effectiveness of programmes”. Patton (2008:39) emphasizes that evaluation is the systematic collection of information about the activities, characteristics and results of interventions within a programme that are utilised to make judgments about the merits or value of a programme with the aim of improving or further develop and to inform decisions about the future programme. Pattons’ definition emphasizes on three important aspects; these are: the systematic collection of information about a programme, a potentially broad range of issues on which evaluations might focus and for a variety of possible judgments and uses. Evaluation is the systematic process of delineating, obtaining, reporting and applying descriptive and judgemental information about some object’s merit, worth, probity, feasibility, safety, significance or equity (Stufflebeam & Shinkfield 2007:698). According to Yarbrough, Shulha, Hopson and Caruthers (2011:287) and Alkin (2011:5), programme evaluation is defined as the systematic investigation of the value, importance of something or someone along defined dimensions. The 25  Literature review 2016 evaluation process can involve ongoing monitoring or one time studies of processes, outcomes and/or programme impact and efficiency. 2.3.1 The purpose of evaluation Babbie and Mouton (2011:337) state that evaluation is one of the cornerstones of professional development activities to manage, improve and refine programmes. Evaluation of the quality of the programme concerning the content and actual delivery should be built into any nurse training programme. Programme evaluation is mostly done by means of questionnaires that participants fill in once the programme has been completed and through interviews (Van der Westhuizen et al 2004:7). The process of evaluation support change in organisations by helping the evaluators and stakeholders to think empirically about “what should be” of the programme (Patton 2008:39). Evaluations are undertaken for very different purposes. LoBiondo-Wood and Haber (2010:417) state that evaluation provides information for performance gap assessment, for audit purposes and giving feedback to stakeholders to determine the expected level of practice in the programme. Furthermore evaluation ensures academic quality assurance required for students expected knowledge and skills to face the dynamic world of their specialised field of practice (Ebisine 2014:7). A three- fold distinction that covers most of these purposes is described by Babbie and Mouton (2011:345) as: judgment-orientated evaluation, improvement orientated evaluation and knowledge orientated evaluations. Judgment orientated evaluations are aimed at establishing the intrinsic value, merit or worth of a programme (Babbie and Mouton 2011:345). Improvement orientated evaluations takes a form of formative, quality enhancement, responsive and empowerment, which all share a concern with improving the programme whilst knowledge orientated evaluations are aimed at generating new knowledge on the understanding of how a programme works and their attributes towards changing the attitudes and behaviour (Babbie & Mouton 2011:347). It is the view of Polit and Beck (2012:260) that when programme evaluations are undertaken the people who are implementing the programme sometimes feel threatened by the evaluation process 26  Literature review 2016 with the thought that their work is evaluated and therefore if found not worthy their jobs are at stake. 2.3.2 Types of evaluation There are different types of evaluations depending on the object being evaluated and the purpose of the evaluation (Babbie & Mouton 2011:339; Fitzpatrick et al 2012:20). Once a decision has been made to design an evaluation study for a programme, choices can be made about the type of approach that will be appropriate and useful. The types of evaluations differ from the evaluation of need, process outcome, impact and efficiency continuum as described in Section 2.2.3.1 to 2.2.3.7. 2.3.2.1 Evaluation of needs “Evaluation of need” is concerned with the determination of areas which require intervention that means concerns in the programme that requires urgent attention or intervention (Terre Blanche and Durrheim 2004:211; Babbie and Mouton 2011:340).The process incorporates analyses of documents, previous research or evaluations of the work of other researchers who already completed the programme evaluation in the same area of interest. Needs assessment identifies the context, provides baseline data on the accomplishment on the area of concern or site for the purpose of selection or adoption of a programme to achieve specific objectives (Mcmillan & Schumacher 2010:435).The evaluation of need of a programme can either be formative with the aim of refining or modifying the programme (Fitzpatrick et al 2012:20) or in the summative form of whether to adopt and continue or terminate the programme (Fitzpatrick et al 2012:26). 2.3.2.1.1 Formative evaluation Formative evaluation uses evaluation methods to improve the way a programme is delivered (Wholey, Hatry, Newcomer 2010:8). Formative evaluation focuses on the process of programme implementation and sometimes overlaps to a process of programme monitoring to establish whether the interventions are implemented as planned (de Vos, Strydom, Fouche & Delport 2011:453). In formative evaluation the individuals taking part are generally those that are responsible for delivering the 27  Literature review 2016 programme or are in a position to make changes in the day-to-day operations of the programme (Potter 2009:412). 2.3.2.1.2 Summative Evaluation Summative evaluation examines the overall quality and outcomes of a programme for decision-making purposes in determining whether the program has met its intended outcomes relative to its cost (Stufflebeam & Shrinkfield 2007:24). In contrast to formative evaluation, summative evaluation is concerned with providing information to assist in making judgments about programme adoption, expansion, continuation or termination based on the criteria for evaluation (Fitzpatrick et al 2012:21 and de Vos et al 2011:459). In addition, Potter (2009:412) states that although summative evaluation often occurs in the later stages of programme development than formative evaluation which occur in the early stages, the two processes are intertwined to achieve better results with regard to programme improvement and to judge its final worth or determine the future of the programme. 2.3.2.2 Evaluation of process Process evaluation monitors the fidelity of the programme or typically monitoring of how the programme is delivered. The process allows early identification of challenges in delivery, evaluates whether the programme is implemented as designed and whether it serves the target population as expected (de Vos et al 2011:457).The authors are of the opinion that evaluation of process permits the stakeholders to judge the extent to which the programme is operating the way is supposed to be, revealing areas which need refining or improvement as well as highlighting the strengths of the programme that could be preserved for utilisation in the future. Evaluation of process can be utilized on improving a new and on an ongoing programme and is therefore linked to formative evaluation (Polit & Beck 2008:317). 2.3.2.3 Evaluation of outcome Evaluation of outcome aims at establishing the relative success or not of an intervention. Rossi et al (2004:234) state that evaluation of outcome is designed to 28  Literature review 2016 determine what effect the programmes have on their intended outcome. Fitzpatrick et al (2012:26) regard programme effect as referring to the description, exploration or determining the change in the target population or social conditions that has been brought about by the programme. Evaluation of outcome can also serve formative and summative purposes. Whereas formative purposes are delivered through immediate outcomes by individual groups responsible for the delivery of the programme, summative purposes are delivered through global outcomes like at the end of the programme to evaluate the success of the programme (Fitzpatrick et al 2012:27). 2.3.2.4 Evaluation of impact Evaluation of impact seek to provide quantitative estimates of the causal effects of programmes (Wholey et al 2011:128).The purpose of impact evaluation is to isolate the effects of the programme to help officials to decide whether the program should be continued, improved or expanded to other identified areas of need (Wholey et al 2011:125). 2.3.2.5 Evaluation of efficiency Efficacy evaluates the cost of an intervention against the benefit (de Vos et al (2011:460). According to Rossi et al (2004:332), evaluation of efficiency includes both cost-benefit and cost utility evaluation. A cost benefit evaluation deals with establishment of estimates for both costs and benefits of the programme to the community whilst cost utility evaluation are expressed in substantive terms for optimal utilisation of allocated resources and the extent to which the programme was effective and cost efficient (Rossi et al 2004:411). Evaluation of efficacy provides information for making decisions about the value of the programme (Oermann & Gaberson 2014:385. 2.3.2.6 Evaluability assessment Evaluability assessment is described as a set of procedures undertaken to determine the readiness of an organization or institution for evaluation (Kreuger & Newman 2006:395). According to Wholey et al (2010:83), the following standards must be met for evaluation to be useful if: 29  Literature review 2016  Program goals are agreed on and realistic  Information needs are well defined  Evaluation data are obtainable  Intended users are willing and able to use evaluation information Evaluability assessment clarifies programme designs and help managers, evaluators and policy makers to redesign programmes so that they meet the evaluability standards as explained by Mertens (2010:80). The author purport that the following principles be assessed before an evaluation can be conducted.  Feasibility: The feasibility standard determines the extent or possibility to which the evaluation can be successfully evaluated in a given setting.  Propriety: Defines the extent to which the evaluation can be humane, ethical, moral, legal and professionally conducted.  Accuracy: The extent, to which the evaluation can be dependent on, be truly and precisely presented and trustworthy.  Utility: Explains the extent to which the evaluation can be valuable to the stakeholders and be appropriately utilised.  Meta-evaluation: Meta-evaluation is the extent to which the quality of the evaluation can be assured. For evaluation to be conducted the above standards have to be properly assessed so that the outcome of the inquiry meet the expected goal. 2.3.2.7 Utilisation evaluation Patton (2008:37) emphasizes the importance of judging the worth of evaluation by their utility. De Vos et al (2011:462) are of the opinion that implementation of the results from an evaluation will help to focus the decision makers towards the areas of improvement in a programme Therefore, it is important to know the extent to which a programme was effective during implementation. Rossi et al (2004:411) suggest the following classification for valuable utilisation of evaluation results:  Direct or instrumental use by decision makers and other stakeholders. 30  Literature review 2016  Conceptual utilisation of evaluations to influence thinking through positive evidence with regard to the evaluation findings without the actual adoption of policies.  Persuasive utilisation where evaluation results are enlisted in an effort to defend or attack political positions. 2.4 TRAUMA/EMERGENCY NURSING EDUCATIONAL PROGRAMME Trauma/emergency nursing emanated from civil wars that occurred in the early 1970 in the United states where the delivery of acute medical care was required to save the lives of the injured people It was then that the increasing recognition of the role of the nurse in the management of the critically ill was given cognisance (McQuillan et al 2009:9). In South Africa the emergency nurse training has been practiced since 1985 at the Tygerberg hospital in Cape Town as a certificate course in collaboration with a hospital in Britain. In 1986 Johannesburg hospital introduced a six months certificate course and from there, other government and private institutions began training nurses for trauma and emergency nursing (Gassiep 2006:45). The programme was approved as a diploma by the South African Nursing Council (SANC) in 1993 (R212 of 1993 as amended by R74 in 1997). Emergency care nursing involves caring for patients with life threatening illnesses and injuries from the scene of initial incident or onset of critical illness at pre-hospital setting through stabilisation and transportation, in-hospital emergency care, intensive care and rehabilitation services. In pre-hospital emergency care the health care professionals are faced with increased demands for efficient and rapid treatment. The practitioner assesses the patients to make decisions about appropriate actions to stabilise the patient and maintain the vital functions (Abelsson & Lindwall 2012:67). According to the teaching guide in clinical course nursing studies for additional qualifications (SANC Regulation 212 1993 as amended by R74 of 1997), all the clinical nursing programmes in medical and surgical nursing comprises a compulsory component in Nursing Dynamics, and an elective component determined by the 31  Literature review 2016 clinical field of study. The elective component in turn consists of two components namely; Internal Medicine and Surgery (Capita Selecta) and Medical and Surgery Nursing Science (Critical care nursing: Trauma) as the area of specialisation. The content included in Nursing Dynamics entails; ethos and professionalism, Health service dynamics, communication and teaching, nursing management and research. Internal medicine and surgery Capita Selecta consist of national, regional and local health profiles, policy-making structures at both macro and micro level as well as national policy, assessment, diagnostic and treatment methods, social, cultural and transcultural considerations in conjunction with aetiology of disease, primary, secondary and tertiary prevention of disease. Medical and surgical nursing science (Critical care nursing: Trauma) addresses professional, ethical and legal norms for practice in trauma/emergency, systematic approaches to assessment and intervention within family groups and community context, referral systems, quality assurance and applied dynamics of nursing practice in the area of specialisation (SANC R212 1993 as amended by R74 of 1997). The areas for rotation of students within the clinical areas for practice includes the emergency unit, intensive care general and cardiothoracic unit, pre-hospital (emergency medical services), operating theatre, burns unit, pediatric intensive care and spinal units. The students are also required to conduct a research study in the area of speciality. The curriculum in this field of speciality is offered for one academic year (44 weeks). The prospective students are expected to have one year of exposure in the trauma/emergency units within the accredited health institutions for training prior to registration for training (SANC R212 1993 as amended by R74 of 1997). 2.5 LEGISLATION INVOLVED IN PROGRAMME EVALUATION In 2001 the World health Assembly passed the resolution WHA 54.12 validating the World Health Organisations (WHO 2009:8) commitment to the scaling up of the health professions. This resolution specifically establishes the imperatives of amongst others the preparation of an action plan with in-build programme evaluation 32  Literature review 2016 procedures. The WHO (2009:22) in its governance further offers the opportunity for nursing education institutions to develop and revise their programmes to meet the needs of the society. The South African National health policy lays emphasis on the provision of a strategy for ongoing support and mentorship in the education and training of health care professionals through continuous quality improvement. The South African Nursing Council (SANC) has been delegated with the authority to administer regulatory and licensing responsibilities by means of the Nursing Act No 33 of 2005. SANC sets the minimum requirements for nurse training. SANC serves as the accrediting body of the training clinical facilities as well as an education and training quality Assurance (ETQA) entity. To ensure and promote uniform standards of training and nursing practice across South Africa, SANC is responsible for regular evaluation of programmes to maintain the quality of training and ensuring that the practice rules and guidelines are followed (South African Nursing Act No 33 of 2005:14). The nursing education institution (NEI) must conduct an annual self-assessment of the effectiveness of its programmes in achieving its stated goals and outcomes in a format determined by the SANC for monitoring and evaluation purposes (Nursing Act No 33 of 2005:14). The nursing education institution must then submit annual returns in a manner determined by the SANC. Other important authorities in South Africa are the South African Qualifications Authority (SAQA) and the National Qualifications Framework (NQF) which has to register all higher education qualifications (Wessels 2001:201). A possible method to evaluate programmes utilising a positive approach to programme evaluation is Appreciative Inquiry (AI).Each component of AI will be discussed in Section 2.4 to 2.6. 2.6 APPRECIATIVE INQUIRY Appreciative Inquiry is defined by Cooperrider, Whitney and Stavros (2008: xv) as a philosophy, relatively new asset-based approach and a process from the field of organisational development that focuses attention for its successful application in facilitating positive organisational change. AI is an organisational development 33  Literature review 2016 methodology that “is a collaborative and highly participative, system-wide approach to seeking, identifying, and enhancing the “life-giving forces” that are present when a system is performing optimally in relation to its whole system of stakeholders, successful and effective (Ludema & Fry 2011:281). 2.6.1 History Appreciative inquiry (AI) is a form of action research that originated in the United States in the mid-1980s and is now being used around the world for organisational development. Appreciative Inquiry was conceived from the foundational work of David Cooperrider and colleagues at Case Western Reserve University (in the Doctoral program in Organisational Behaviour that was created in 1960 by Herb Shephard) and the Taos Institute work (Preskill & Catsambas 2006:8; Reed 2007:22). The Taos Institute became known for the successful training provided to various organisations and educators in various social fields (Watkins & Mohr 2001:18). AI reflects the core values of organisational development (OD) practice and theory developed over the last half century as a source to encourage people to rethink and enlarge on how to approach work as organisation development professionals, possibly leading to a reinventing of organisational development itself (Cooperrider, Whitney & Stavros 2003:14). When David Cooperrider was doing his PhD, he interviewed leading clinicians in the United States at the Cleveland Clinic about their greatest successes and failures. Cooperrider found himself drawn to the stories of success and focused exclusively on them. The goal for Cooperriders’ research was to develop a grounded theory of participatory management. Cooperriders theoretical framework for the research was social constructionist. The research report had a huge impact on the clinic so much so that the Clinic board asked that the same approach be used throughout the organisation (Coghlan,Preskill & Catsambas 2003:7). In addition to the social constructionist framework Cooperriders’ Appreciative Inquiry approach drew upon scientific research into the power of positive images to change behaviour, in particular studies to name a few; the placebo effect, the pigmalion effect, positive effect, inner dialogue, positive imagery and meta-cognition and evolution of positive images (Watkins & Mohr 2001:21). 34  Literature review 2016 The placebo effect studies in (Cooperrider et al 2008:10) is a process in which projected images ignited a healing response in patients with positive belief that they were receiving effective treatment. In the pigmalion studies the belief that randomly chosen students were more intelligent, turned out to be real in that students were perceived to be better performing than other groups. The reality was due to the teachers differing subconscious interactions with the student groups (Cooperrider et al 2008:11). The author argued that all human systems exhibit a continuing future visual imagery though the notion of inner dialogue that creates guiding images of the future from the collective inner dialectic between positive and negative adaptive statements. 2.6.2 Defining Appreciative Inquiry The words “appreciate” and “inquire” are defined in Cooperrider et al (2003:1) as: To Ap-pre’ci-ate means valuing; the act of recognizing the best in people or the world around us; affirming past and present strengths, successes, and potentials; to perceive those things that give life (health, vitality, excellence) to living systems; to increase in value, e.g. the economy has appreciated in value. To “In-quire” means the act of exploration and discovery to ask questions; to be open to seeing new potentials and possibilities. Appreciative Inquiry is the cooperative, co-evolutionary search for the best in people, their organisations, and the world around them. It involves the discovery of what gives “life” to a living system when it is most effective, alive and constructively capable in economic, ecological, and human terms. AI involves the art and practice of asking questions that strengthen a systems’ capacity to apprehend, anticipate, and heighten positive potential (Cooperrider et al. 2003: 3). Appreciative Inquiry is based on the assumption that every organisation, be it educational industrial religious or otherwise, has something that works right and pertains processes and issues that give the organisation life when it is most alive, effective, successful, and connected in healthy ways to its stakeholders and communities (Cooperider et al 2008: XV). Appreciative Inquiry is a process that enquires into identifies, and further develops the best of what is in organisations in 35  Literature review 2016 order to create a better future. A fundamental premise is that “organisations move toward what they study” (Cooperrider et al 2003: 29). Cooperrider further explains that Appreciative Inquiry begins by identifying what is positive and connecting to it in ways that heighten energy and motivate stakeholders to envision the future action for positive change.Cooperrider and Whitney (2003:15) define Appreciative Inquiry as the cooperative search for the best in people, their organisations, and the world around them. In contrast with traditional organisational development methods which seek out problems in the organisation and work to fix them, AI involves systematic discovery of what gives ‘life’ to a living system when it is most alive, most effective, and most constructively comparable to attain success (Bushe & Kassam 2005:161;Gimore 2007:100). According to Whitney and Trosten-Bloom (2003:2) appreciating refers to the act of recognition of value, success and gratefulness as well as the act of enhancing the value of an organisation. The authors define inquiry as the act of exploration and discovery, thus involving the search for new potential to change. Coghlan, Preskill and Catsambas (2003:6) describe AI as both a philosophy and a worldview, with particular principles and assumptions and a structured set of core processes and practices for engaging people in identifying positive possibilities and co-creating an improved and better future for organisations. Appreciative inquiry is a form of social construction in action particularly focused on social relationships and human interaction where new knowledge can be generated to promote a better understanding of the social world while transforming communities, programmes, organisations and individuals (Reed 2007:viii). 2.6.3 Appreciative inquiry approach versus problem solving approach The basic assumption of problem solving is that an organisation is a problem to be solved. In contrast the underlying assumption in AI is that an organisation is a solution to be embraced rather than a problem to be solved (Cooperrider, Whitney & Stravros 2008:5). Cooperrider’s experience from his doctoral work with AI in Cleveland clinic in 1987 led to the proposal of AI as an alternative methodology for organisational improvement. Cooperrider identified fault with the problem solving focus that was usually related with deficiency mode of thought by directing the focus 36  Literature review 2016 on restoring the status quo to organisations rather than generating theories for new ideas and actions for positive change. In addition Norum, Wells, Hoadley and Geary (2002:10) as supported by van Buskirk (2002:67) concur with the notion that “the difference in using the AI approach is that instead of dwelling on the “problem” the conversation focuses on suggestions for what could be done about the problem by creating generative possibilities. Furthermore, Bushe and Kassam (2005:3) agree with the previous authors that AI emphasises the creation of new knowledge within the organisation that compels new action. Ashford and Patkar (2001:4) state that a common underlying assumption of the problem-solving approach is that organisations are best served by identifying and removing their deficits,in contrast, Appreciative Inquiry argues that organisations improve more effectively through discovery and valuing, envisioning, dialogue and co-constructing the future. Drucker (2006:18) is of the opinion that the task of leadership in an organisation is to create an alignment of strengths in ways that make the system’s weakness irrelevant. It his is noteworthy that Messerschmidt (2008:455) supports this opinion in his idea that Appreciative Inquiry approach seek to turn problems into their positive opposites by focusing attention on the exceptions to the problems and building upon exceptional successes. In the same vein, Michael (2005:223) affirms the idea on the note that when using AI, the best positive option is chosen as a starting point from which to work for the success of the organisation or programme. It is reasonable, then, that Egan and Lancaster (2005:30) argue that traditional problem solving approach limits the opportunities for organisations to be successful because it reinforces the existing beliefs instead of addressing the possibilities for the creation of new beliefs”. In Table 2.1. A summary of the comparison between problem solving and Appreciative Inquiry process is provided. 37  Literature review 2016 Table 2.1: Comparison of problem solving and Appreciative Inquiry process Problem solving Appreciative inquiry "Felt need" Appreciating and valuing Identification of Problem the best of "what is" Analysis of causes Envisioning "what might be" Analysis of possible solutions Dialoguing "What should be" Action planning (treatment) Innovating "What will be Basic Assumption: An organisation is a problem Basic Assumption: An organisation is a mystery to be solved. to be embraced. Source: Adapted from Cooperrider et al (2008:16) The information given in the Table 2.1 gives a brief discussion on the emphasis of Appreciative Inquiry utilisation in organisations as compared to problem solving strategies. AI is an approach to positive organisational change based on assumptions that organisations are creative centers of human relatedness and unlimited emergent capacity to respond to reality (Cooperrider et al 2008:17). 2.6.4 Principles Couglan et al (2003:6) argue that AI is both a philosophy and a worldview, with particular principles and assumptions and structured set of core processes and practices for engaging people in identifying and co-creating an organisation or programmes’ future. Appreciative Inquiry is based on the core principles and assumptions that inspired and moved the foundation of AI from theory to practice (Cooperrider et al. 2005:8).The principles for appreciative Inquiry were born out of theories and related studies (Preskill and Catsambas 2006:11). The five basic principles include (a) constructionist principle, (b) simultaneity principle, (c) the anticipatory principle, (d) the poetic principle and (e) the positive principle. To reinforce these principles, Preskill and Catsambas (2006:9) subsequently added three more. The additional principles are: (f) the wholeness principle, (g) the enactment principle and (h) the free choice principle. Barret and Fry (2005:49) brought principle called (i) the narrative principle whilst Stavros and Torres (2005:79) came with (j) the awareness principle. A summary of the eleven principles of AI is reflected in Table 2.2. 38  Literature review 2016 Table 2.1: Summary of the principles of Appreciative Inquiry Principle Definition Constructionist principle The constructionist principle argues that an organisation’s reality is constructed by the questions people ask. How knowledge is generated in the organisation will determine its future Principle of simultaneity The principle of simultaneity recognizes that inquiry and change cannot be kept separate but occurs simultaneously. The moment questions are articulated change is initiated. Dialogue shapes images of the future which then form into reality Poetic principle The poetic principle states that organisations are like open books, their stories being constantly co-authored by their members. The choice of topic for a story can alter the organisation; stories about success will lead to a different organisation than stories about failure Anticipatory principle The anticipatory principle views collective imagination and discourse as the most important source for generating constructive organisational change. By changing the image of the future, the future will be changed. Positive principle The positive principle states that the more positive a change initiative is framed, the more effective and long lasting it will be. Humans are responsive to hope, inspiration, positive stories and bonding with other people. Positive images lead to positive change Positive questions lead to positive change. The momentum for change requires positive affect and social bonding. The change momentum is best generated through positive questions that amplify the positive core. Wholeness principle The Wholeness brings out the best in people and organisations. Bringing the stakeholders together in a large group forum stimulates creativity and builds collective capacity. Enactment principle Acting “as if” is self-fulfilling To make change we must “be the change we want to see”. Positive change occurs when the process used to create the change is a living model of the ideal future Free choice principle Free choice liberates power. People perform better and more committed when they have freedom to choose how and what they contribute. Free choice stimulates organisational excellence and positive change Narrative principle Narratives are stories constructed from collective individuals’ lives. Barrett and Fry further believe that stories are transformational. People Construct stories about their past life experiences which can be used to shape the future. 39  Literature review 2016 Principle Definition Awareness principle Understanding and being aware of our underlying assumptions are important to developing and cultivating good relationships. Practicing cycles of action and reflection can build one’s self-awareness. Adapted from Whitney and Trostem-Bloom (2003:54-55) and Cooperrider, Whitney and Stavros (2003: 8-9) 2.6.5 Appreciative inquiry and positive change AI is believed to be a transformative and empowering change model which is solution-centered rather than problem-centered (English, Fenwick & Parsons 2003:71). The authors further argue that Appreciative Inquiry looks at organisational issues, challenges, and concerns in a significantly different way. Instead of focusing on problems, organisational members first discover what is working particularly well in their organisation. Then, instead of analyzing possible causes and solutions, they envision what it might be like if “the best of what is” occurred more frequently. Here participants engage in a dialogue concerning what is needed, in terms of both tasks and resources, to bring about the desired future. Finally, organisation members implement their desired changes (Reason and Bradbury 2011:282). “The principle of simultaneity recognizes that inquiry and change are not separate…” (Watkins & Mohr, 2001:38). AI is based on the assumption that change occurs in the direction in which the inquiry is made (Cooperrider & Whitney 2000:4). “Human beings and organisations move in the direction that they inquire about…” (Watkins & Mohr 2001:39). According to Watkins and Mohr (2001:38), the momentum for change requires large amounts of both positive affect and social bonding and includes things like hope, inspiration, and sheer joy in creating with one another (Watkins & Mohr 2001: 38). In view of Cooperrider and Whitney (2001:21), AI is a process that inquires in ways that refashion anticipatory reality through the positive imaginary focus. Bushe (2001:88) believes that the power of AI taps into the stories of what an organisation’s members believe is best and those stories can be used to create new futures for the organisation. Cooperrider et al (2003:29) state that organisations have an inner dialogue composed of information exchanged by members, often through the form of stories, 40  Literature review 2016 any changes to the content of these stories, (framing or focusing the stories) changes the inner dialogue and hence the trajectory of the organisation. The authors further noted that Appreciative Inquiry does reveal patterns of preference within an organisational population and also values inquiry, dialogue and reflection, so long as they lead to clearer delineations of instances in which positive deviance has been beneficial. Appreciative Inquiry is viewed by Watkins & Mohr (2001: xxxi) as a theory and practice for approaching change from a holistic framework. Based on the belief that human systems are made and imagined by those who live and work within them, the authors believe that AI leads systems to move toward the generative and creative images that reside in their most positive core which involves the values, visions, achievements, and best practices within the organisation. In practice, AI can be used to co-create the transformative processes and positive practices appropriate to the culture of a particular organisation. Watkins and Mohr (2001: xxxi) further purport that once the organisation members shift their perspective from ruling out the source of the problem and changing to valuing the best of what is; they can begin to invent their most desired future. People are more likely to engage in thinking through and acting on change strategies if the process begins with a positive stance (Reed 2007:47). The positive principle states that the more positive a change initiative is framed, the more effective and long lasting it will be. Humans are responsive to hope, inspiration, positive stories and bonding with other people. By changing the image of the future, the future will be changed, as positive images lead to positive change (Cooperrider, Whitney & Stavros 2003:8). According to Cooperrider et al (2008:120), positive imagery influences the fate of an organisation or programme. A positive vision of the future makes the activities of individuals in an organisation to flourish. The heliotropic theory hypothesizes that human systems move in the direction of positive images (Cooperrider et al 2008:13). AI involves, in a central way, the art and practice of asking questions that strengthen a system’s capacity to apprehend, anticipate, and heighten positive potential 41  Literature review 2016 (Cooperider & Whitney 2000:3). AI fundamentally seeks out what has worked well in the past and guides participants through a process to build on these successes. Watkins and Mohr (2001:21) assert that AI is a fundamental shift in thinking and so it is viewed as more than a “tool”, “technique”, or “intervention” towards success. 2.7 EVALUATION METHOD Appreciative Inquiry and evaluation emphasize social constructivism, especially in the sense that making and meaning are achieved through dialogue and interaction. AI and learning orientation forms of evaluation view inquiry as ongoing iterative and integrated into organisational life (Preskill & Coglan 2004:16). AI is a dynamic approach and method to evaluation practice, that offers excellent potential to engage people in participatory evaluation for continuous improvement and most importantly, sustainable implementation (Cojoracu 2008:2010). Watkins and Mohr (2001:183) state that AI is grounded in the belief that the intervention into any human systems is fateful and that the system will move in the direction of the first questions that are asked. The first questions often asked focuses on stories of best practices, positive moments and successful processes that allow creation of images of a future built on those positive experiences from the past. Van de Haar and Hosking (2004:1031) argue that AI and evaluation should not be understood as two separate and independent activities. Rather, they could be thought of as an interwoven and ongoing process. In the same vein, Preskill and Catsambas (2006:40) claim that “Appreciative Inquiry can be an effective approach to obtaining information for programme evaluation plan since it involves informative stakeholders, assists participants understand the evaluation’s purpose and the intended uses of the findings. The authors state that AI is a positive approach to addressing the evaluative issue. The authors concur with Watkins and Mohr (2001:183) and add that using Appreciative inquiry in evaluation engages the stakeholders in the process of identifying and creating an evaluation system that is based on the current situation and what worked well in the past. 42  Literature review 2016 Coghlan et al (2003:19) believe that Appreciative inquiry works best in the following evaluation situations; namely  Where previous evaluation efforts have failed.  Fear or scepticism surrounding the evaluation.  Limited knowledge of each other on the group of or knowledge on the programme for evaluation.  Hostile environment for evaluation to take place.  Situations where change is an immediate need.  Where dialogue will create a critical outcome.  Among individuals or groups where relationships have deteriorated or have reached a state of hopelessness.  Circumstances where there is a desire to help others learn through evaluation or to build a community of practice.  Areas where building support for evaluation and for the programme being evaluated is a desired outcome. Watkins and Mohr (2001:182) argue that traditional evaluation is about determining how inputs have led to outputs, what the return from investment was, and whether goals have been achieved. The authors however believe that, as an alternative to traditional evaluation, there must be a proposal to use an appreciative approach to evaluation to determine the quality of the practice in a programme. This argument is based on the assumption that every intervention in any human system will move in the direction of the first questions asked. Bushe (2007:30) is of the opinion that a successful appreciative evaluation generates spontaneous, individual, group and organisational action toward a better future”. Therefore, it is better to evaluate from an ‘AI perspective’ and to focus on stories of best practices and moments of success. The standard process for evaluating a programme consists of almost similar activities as in Appreciative Inquiry. The difference lies in the approach. These standards can be applied both while planning an evaluation and throughout its implementation (Milstein, Wetterhal & CDC 2000:222). A comparison of the two processes is given in Table 2.3. below. 43  Literature review 2016 Table 2.2: Comparison of programme evaluation process and Appreciative Inquiry Programme Evaluation process Appreciative Inquiry process 1. Engage Stakeholders: After becoming involved, 1. Define: Engaging all relevant and interested the identified stakeholders help with execution of people in positive change. The phase involves the other steps. Key stakeholder groups are designing what the focus of the study is and regarded as those individuals involved in creating the inquiry process. programme operations, those affected by the programme, and primary users of the evaluation. 2. Describe The Programme: e.g. mission, 2. Discovery (appreciate): The phase objectives, strategies, expected effects, resources, consists of participants interviewing each other and stage of development of the programme are sharing stories about their peak experiences e.g. described. The logic picture of the model that asking questions like; what is it that you most value displays how the entire programme is supposed to about yourself, your work, and your organisation? , work is given. What three wishes do you have to enhance the quality of nursing education institutions and vitality? Groups develop an interview protocol based on the key themes arising out of the narrated stories. Using the developed protocol, interviews are conducted with as many organisation members as possible, ideally by the members themselves. 3. Focus the Evaluation Design: The main focus 3. Dream (envision results): The participants is given to the following important considerations on envision themselves and their organisation evaluations, that is, purpose, users, uses, functioning at their best. Through various kinds of questions, methods, and the agreements that visualisation and other creative exercises, summarize roles, responsibilities, budgets, and participants think broadly and holistically about a deliverables for those who will conduct the desirable future. evaluation. 4. Gather Credible Evidence: Identification of the 4. Design (co-construct the future): stakeholders’ criteria for acceptable evidence, In these phase participants propose strategies, nature of indicators, sources, how to gather and processes, and systems; make decisions; and handle evidence. develop collaborations that will create and support positive change. They develop provocative propositions or possibility and design statements that are concrete, develop detailed visions based on what was discovered about the past successes. 44  Literature review 2016 Programme Evaluation process Appreciative Inquiry process 5. Justify Conclusions: Data is considered from a 5. Destiny (sustain the change): The determined number of different stakeholder perspectives, to visions of the Dream phase and propositions of the reach conclusions that are justified. Conclusions Design stage are implemented. This phase is become justified when they are linked to the ongoing as participants continue to implement evidence gathered and are consistent with, agreed- changes, monitor their progress, and engage in on values or standards set by stakeholders. The new dialogue and Appreciative Inquiries. process of reaching justified conclusions involves the following basic steps: (a) analysis/synthesis of the data to determine the findings; (b) interpretation, to determine what those findings mean; (c) judgments, to determine how the findings should be valued, based on the selected standards; and (d) recommendations, to determine what claims, if any, are indicated. 6. Ensure Use and Share Lessons Learned: 6. Feedback is given to the relevant stakeholders Depending on the outcome of evaluation, some involved with practice of the programme to sustain activities that promote use and dissemination the change process for desired goal. include designing the evaluation from the start to achieve intended uses, preparing stakeholders for eventual use, providing continuous feedback to stakeholders, scheduling follow-up meetings with intended users to facilitate the transfer of conclusions into appropriate actions or decisions, and disseminating lessons learned to those who have a need or a right to know or an interest in the programme. Adapted from Milstein, Wetterhall and CDC Evaluation working group (2000:222), Whitney and Trosten- Bloom (2003:6) and Cooperrider Whitney and Stavros (2005:5). Table 2.6 gives a brief explanation on the process undertaken in evaluation as compared to Appreciative Inquiry. The comparison reveals a lot of similarities in the two processes. Appreciative Inquiry can be utilised as an approach to evaluating a programme. The advantages of using appreciative inquiry in evaluation will be discussed in section 2.3. 45  Literature review 2016 2.8 ADVANTAGES To begin with, McNamee (2003:37) expresses views on how using AI makes it easier to evaluate when using an appreciative stance. The author further adds that AI brings conversational freedom in the appreciative context when discussing difficulties to make them more open and possible. An advantage of applying AI to evaluation is based in its infinite flexibility depending on the organisation or programme for evaluation (Preskill and Catsambas 2006:50).The authors further believe that using an AI approach may also counter some participants’ negative perceptions of evaluation by establishing a positive atmosphere focused on successful experiences to create a positive future (Preskill and Catsambas 2006:59). Whitney and Trosten-Bloom (2003:20) believe that AI creates an opportunity for people to be heard with recognition and respect and thus generate the opportunity to share their dreams and increase confidence, moral and improve trust and sense of belonging. Reed (2007:420) states that AI is essentially a methodology that focuses on supporting people to get together in sharing stories of positive development in their organisations to build the future. Appreciative inquiry creates a construction of a common ground image for the future as it accelerates organisational learning by speeding up innovation and creativity (Cooperrider et al 2005: xix). AI encourages long term positive organisational change (Stavros et al 2003:8, Bushe 2011 :19). AI, as an evaluation philosophy and tool, is based on the alluring premise that by concentrating on the positive aspects of an organisation, more favourable outcomes will be experienced. It is noteworthy that Preskill and Catsambas (2006:26) believe that Appreciative Inquiry addresses challenges, problems and conflicts within organisations by shifting the focus towards hope and possibilities of experiences which worked well in the past. AI is therefore a vital component for initiating change in creating positive collective visions and actions within an institution (Trajkovski, Schmied & Vickers 2015:241). For sustainable development, Appreciative Inquiry promotes positive goals and strives to inject hope and optimism for a better future. 46  Literature review 2016 2.9 CRITIQUE ON APPRECIATIVE INQUIRY Appreciative Inquiry assumes that people can find positive parts of their practice which can take their attention away from the problems and deficits of their practice and redirect their attention to the best of what exists alongside the possibilities of what could be (Whitney & Trosten-Bloom 2003:18). There are a number of questions raised about AI, more especially on its strength based orientation. Rogers and Fraser (2003:77) question whether AI encourages ‘unrealistic and dysfunctional perceptions, attitudes, and behaviour. The positive focus of AI is sometimes seen as not reflecting handling of negative theoretical ideas that might arise during the process of inquiry, but ignoring or neglecting the negative stories (Reed 2007:75).The positivity focus that Appreciative inquiry insists on does not ignore problems, and neither does it deny problems (Preskill & Catsambas 2006:26;Whitney & Trostem-Bloom 2003:18). Problems are solved by focusing on what has worked and therefore knowing what to do, and removing or refraining from what will not work (Preskill & Catsambas 2006:27,Kadi–Hanifi, Dagman, Peters, Snell, Tutton, & Wright 2013:585). In contrast, Fineman (2006:308) concede that researchers have so far less attracted to the positive discourse. According to Fitzgerald, Oliver & Hoxsey (2010:221) and Pratt (2002:117), AI can surface repressed or censored thoughts and feelings that may be valuable in the future success of the organisation. Pratt (2002:100) is of the opinion that during the process of unfolding stories in Appreciative inquiry, the positive focus turn to create an apparent refusal to honour negative dimensions of lived experience seem to compromise the truth and honesty of the AI process. However, Bushe (2007:1) is concerned about every action that is thought as positive being equated to AI by people who do not understand the fundamentals of AI. It is in this cautionary sense that Golembiewski (2000:55) refers to AI as “discouraging inquiry” that imposes positivity. 47  Literature review 2016 2.10 CONCLUSION In this literature review the programme evaluation and the Appreciative Inquiry were outlined. A shift in the traditional methodology from problem solving to Appreciative evaluation was indicated. Chapter 3 will provide an in-depth discussion of the research methodology that was used to conduct the study. 48  Research design and methods 2016 CHAPTER 3: RESEARCH DESIGN AND METHODS 3.1 INTRODUCTION In Chapter 2 the literature review pertaining to programme evaluation and Appreciative Inquiry was delineated. In this chapter the setting for the study, research design, research method for addressing the research question, data collection method and analysis will be described at length. 3.1.1 Setting The study was carried out in a provincial public institution in the Limpopo province of the Republic of South Africa. The institution is described as a tertiary institution, catering for all the districts and provincial hospitals in terms of the provincial health institution classification. It is designated as a multi-disciplinary and training institution that offers amongst others post basic “medical and surgical” nurse training as accredited by the South African Nursing Council (SANC).The invited participants were from the institutions around the Limpopo province. The venue for conducting the study was at the learning centre situated in the premises of the institution away from the daily activities of the institution. The venue has four spacious rooms which accommodate 25 to 35 individuals, a kitchen, office areas and rest rooms. The invited participants were divided into two groups and allocated to two rooms. The participants were seated around the table convenient for interviews, better facilitation and communication. 3.2 RESEARCH DESIGN Research design is described by Parahoo (2006:183) as a plan that explains how research is going to be conducted, indicating who or what is involved, when and where data is to be collected. The authors believe that it is therefore important that the researcher chooses the most appropriate design to meet the aims and objectives of the study. In addition, Polit and Beck (2012:741); Rebar, Gersch, Mcnee and 49  Research design and methods 2016 McCabe (2011:175) define research design as the overall plan for the systematic approach for acquiring knowledge in a way that ensures that the answer(s) found in the study are as meaningful and accurate as possible to the research question. Furthermore, Burns, Grove and Gray (2013:692) state that the research design guides the planning and implementation of the study in a way that it will most likely achieve the intended goal. In order to achieve the goal, a strategy or a plan is required to conduct the study. For the purpose of this study, a qualitative research design was chosen. Polit and Beck (2012:14) define qualitative research as naturalistic methods of inquiry that attempt to deal with the issue of human by exploring it directly. According to Creswell (2014:4) qualitative research is based on assumptions, a world view, the possible use of a theoretical lens, and a study of research problems inquiring into the meaning that individuals or groups’ attribute to a social or human phenomenon. It is the firmly held view of Speziale and Carpenter (2007:21) that qualitative research focuses on finding answers to questions centered on social experience, how it is created and how it gives meaning to human life. The authors argue that in qualitative research, multiple realities occur as individuals participate in social actions based on previous experience, understanding the phenomenon in a different way. Therefore, multiple realities held by different individuals are to be considered to fully understand the reality in the past or current social activities they are engaged in. The primary goal of studies using a qualitative approach is understanding, describing and interpreting rather than explaining human behaviour (Babbie & Mouton 2011:270; de Vos, Strydom, Fouche & Delport 2011:64;Holloway & Wheeler 2010:3; Leedy & Ormrod 2013:139). According to Bless, Higson-Smith and Sithole (2013:16) the goal of qualitative research is to yield insight into human activities and opinions from the perspective/point of view of the participants. In this study, the selected participants have specific experiences pertaining to the emergency nursing programme. They were considered relevant to sharing their experiences on the education and training received in the programme. The qualitative approach gives the researcher a complete picture of the study through the 50  Research design and methods 2016 participants’ interpretations of activities in the theoretical and clinical component as practiced in the programme offered by the Nursing Education Institution (NEI) in the Limpopo Province. The researcher’s aim to evaluate the emergency nursing programme is with a view to gaining an understanding of that which was positive about the programme and identify the challenges that can be addressed to improve the quality of education and training of the programme, based on the views and interpretation of students who underwent the training programme. 3.2.1 Characteristics of qualitative research The different qualitative designs share common characteristics. The following characteristics are inherent to most qualitative research: 3.2.1.1 Natural setting Qualitative research is naturalistic to an extent that the research takes place in the real world setting, that is, the normal course of events where the researcher does not attempt to manipulate the phenomenon of interest (Babbie & Mouton 2011:270). Again, it is noteworthy that qualitative research is undertaken at the field where participants experience the issues under study (Creswell 2014:185; Holloway & Wheeler 2010:5). It therefore focuses on the need to acquire informed consent from the participants (Lobiondo-Wood & Haber 2010:117). The study was undertaken at a Nursing Education Institution in the Limpopo Province where the participants were trained for an additional qualification in emergency nursing. 3.2.1.2 Researcher as the key instrument The researcher as an instrument in qualitative research takes a transformative role during the research process. The process of data collection involves examining documents, observing behaviour and interviewing participants from a small number of participants using interview schedule (Creswell 2014:185; Holloway & Wheeler 2010:9). The researcher takes a leading role in data collection acknowledging any personal bias. The findings of the study must be accurately done in a way that reflects the reality of the participants’ experiences (Lobiondo-Wood & Haber 51  Research design and methods 2016 2010:118). An independent facilitator was utilized by the researcher especially for the data collection process. In this study the interview guide (view Annexure D) based on appreciative inquiry, was developed by the researcher in collaboration with the supervisors for data collection. Following the questions on the interview schedule the participants’ experiences were transformed into language for better understanding of the original experiences that were shared by the participants. The participants’ experiences were captured on audiotape and translated into a written document. The resulting synthesis of captured information gives meaning to the “whole” experiences giving a description and interpretation of the participants’ experiences of the emergency nursing programme as translated by Creswell (2014:185). 3.2.1.3 Participants’ meaning The researcher is focused on deeper understanding that the participants hold pertaining to the study, not the meaning that the researchers bring to the research. The researchers’ attempt in qualitative study is to view the world under study from the participants’ perspective and that is referred to as the insiders’ perspective or an ‘emic’ perspective (Creswell 2014:185; Holloway & Wheeler 2010:6). The researcher is a nurse educator responsible for the education and training of the emergency nursing programme and has to consider the participants’ view pertaining to their experiences of the theoretical and practical component of the programme. 3.2.1.4 Holistic account The plan for inquiry cannot be tightly prescribed and the phases of the process may change as the information unfolds (Creswell 2014:186; Gray 2009:166; de Vos et al 2011:64). Social phenomena are viewed in totality to make a broad analysis and give a holistic view of complex interactions of factors occurring in a particular situation (Creswell 2009:176). In this study related experiences and inputs from participants were all given consideration to have a better understanding of the interpretation of the emergency nursing programme as a whole, which includes the theoretical and practical component of the programme. 52  Research design and methods 2016 3.2.1.5 Emergent design This involves reporting multiple perspectives, identification of factors involved in a situation and sketching the larger picture that emerges. The initial plan in qualitative research cannot be tightly prescribed; the process might shift during data collection (Creswell 2014:186). As the data collection process continued, the emerging themes were also taken into consideration in the analysis of data to give more complete descriptions of the study. 3.1.1.6 Inductive data analysis In qualitative research inductive data analysis approach is followed where the researcher builds patterns from the unveiling data into categories, themes and subthemes from the bottom up by organising the data into increasingly abstract units of information, based on interpretations of the first order description of events (Babbie & Mouton 2011:273). The qualitative approach is classified as unstructured as it allows flexibility between themes and the database until they establish a comprehensive set of themes (Creswell 2013:2; de Vos et al 2011:65). The major concern to the researcher in this study is to attempt to understand the participants in terms of the reality of the world in the practice of the programme. With this in mind, the collected data was accordingly synthesized into themes and categories that were ultimately analysed to give meaning to the outcome of the study. 3.2.1.7 Interpretive design Qualitative research is a form of inquiry in which researchers, make an interpretation from the collected data when a research report is issued. Reporting of qualitative study findings have to be true and representative from the perspectives of the individuals who lived the experiences (Speziale & Carpenter 2007:23).The interpretation is also made by participants and readers interested in the research (Creswell 2014:194). This means that qualitative research formulates and interprets data. This includes developing a description of an individual setting, analysing data for themes or categories and finally making an interpretation of how multiple views of 53  Research design and methods 2016 a situation can emerge and finally drawing a conclusion about its meaning personally and theoretically (Creswell 2014:158). The researcher and the independent facilitator of the focus groups made interpretations from the information that was provided by the participants. Once the focus group interviews were translated, the data was then forwarded to the independent coder for confirmation of meanings that the participants attached to their experiences. Considering the above characteristics, qualitative descriptive research approach was used for this study because it is systematic and realistic in capturing people’s experiences. The qualitative approach allowed the researcher to explore the depth, richness, complexity, understanding and the meaning attached to the participants’ experiences pertaining to the emergency nursing programme. 3.2.2 Explorative design Exploratory research designs are aimed at increasing knowledge in a field of study and are not intended for the generalization of the results to large populations(Burns and Grove 2009:359). It is with view of Babbie and Mouton (2010:92), considered in tandem with Bless, Higson-Smith and Sithole (2013:57), that research is deemed exploratory when a researcher examines a topic of field of study that is relatively new in order to gain new understanding of the phenomenon. As the emergency programme in the NEI in Limpopo was not formally evaluated since its inception in 2007, an exploratory design was deemed an ideal fit for the research question. 3.2.3 Descriptive design Descriptive design is regarded as a study that seek to draw a picture of a specific details of a situation, social setting, person, event or show how things are related to each other (Gray 2011:35;de Vos et al 2011:96). In addition, Burns and Grove (2009:359) describe descriptive design as a design used to gain information about characteristics within a particular field of study and its purpose being the provision of a picture of a reality. Descriptive design is therefore used to explore the status of 54  Research design and methods 2016 some phenomenon and to describe what exist with respect to the individual, group or condition. Descriptive design is explained by Parahoo (2006:467) supported by Polit and Beck (2012:226) as a kind of design that is based on general premises of naturalistic inquiry as information gathered from descriptive content that emerges from the participants. Qualitative researchers are primarily interested in describing the actions of the research participants in detail and then attempting to understand the meaning of these actions in terms of the researcher’s own belief, history and content (Babbie & Mouton 2011:272).The authors thus speculate that this is the main reason for the researchers preference in using categories and themes that come from the participants ‘emerging data to stay true to the meaning of the data. The design was premised on the assumption by the researcher that relevant data on the emergency nursing was contained within those professional nurses that had experience in the education training at a Nursing Education Institution in the Limpopo Province. This study was descriptive in nature because it described in words (Merriam 2009:16) the reality of the activities in the programme as viewed by the participants to make clear for the understanding and meaning of the data. Based on the findings from the study, recommendations could therefore be made with regard to what work well as well as what could be improved. In this study the researcher attempted to understand and describe the views of the professional nurses with regard to the education and training received during the training in the emergency nursing programme. 3.3 RESEARCH METHODS The research method is described by Polit and Beck (2012:12) as the technique used to structure a study and to gather and analyse information in a systematic way. The research methods that will be utilised in this study will be explained in terms of the sampling, population, inclusion criteria, sample size, data collection and data analysis methods. Each of these components will be discussed in section 3.4.1 to 3.4.5. 55  Research design and methods 2016 3.3.1 Sampling Sampling is defined by de Vos et al (2011:390) and Polit and Beck (2012:742) as the process of selecting a portion of the population from the researcher’s group of interest to represent the entire population in order to obtain information regarding the phenomenon of interest. The aim of sampling is to study all the components that may form the population of interest to increase the efficacy of a research study (Lobiondo & Haber 2010:224). In addition, Saks and Allsop (2013:172) explain sampling as the method or practice of selecting information from the population to represent the entire population so that inferences about the population can be made from the collected data. The researcher’s sample is representative segments of the population as it is rarely feasible to sample the entire population of interest (LoBiondo-Wood & Haber 2010:221). Sampling in qualitative research is done for the sake of meanings that people give to social situations has to be tied to the study objectives (Liamputtong 2010:11). For the purpose of this study the sample comprised of professional nurses who were trained for the emergency nursing programme at the nursing education institution in the Limpopo province from 2007 to 2013. 3.3.1.1 Population Population is defined as a group or a complete set of persons or objects that possess some common characteristics that is of interest to the researcher (Brink, van der Walt & van Rensburg 2012:131; de Vos et al 2011:223; Burns & Grove 2009:42; LoBiondo & Haber 2010:221). Population is viewed by Gray (2011:148) as the total number of possible units or elements that are included in the study. Polit and Beck (2012:738) add that the population is the entire aggregation of cases that meet a specified set of criteria for a research study, and can be seen as that which sets boundaries for s study. The target population is described by Polit and Beck (2012:744) as the aggregate of cases about which the researcher would like to generalize. Accessible population is 56  Research design and methods 2016 defined as the population of people, who conform to designated criteria available for a particular study (LoBiondo & Haber 2010:221; Polit & Beck 2012:744;Grove,Burns &Gray 2013:352). The target population in this study comprised of professional nurses with additional qualification in Critical Care Nursing: Emergency obtained from the Nursing Education Institution in Limpopo from 2010 to 2013. 3.3.1.2 Inclusion criteria The criteria that specify population characteristics are referred to as inclusion criteria (Polit & Beck 2012:274).Inclusion criteria give direction or a list of the characteristics essential for inclusion in the sample (Burns & Grove 2009:345) and also depends on the aim of the study (Holloway & Wheeler 2010:114).The authors belief that voluntary participation is one of the most important inclusion criteria. The inclusion criteria followed for participation in the study was professional nurses who completed training in emergency Nursing as an additional qualification obtained from the Nursing Education Institution in the Limpopo Province between 2007 and 2013.The participants included also students who have just completed the 2013 summative examination. 3.3.1.3 Non-probability sampling Non-probability purposeful sampling was used because it was consistent with the objectives of the study which were to evaluate the emergency nursing programme in which the participants were intentionally sought for their ability to inform the research from accounts of their personal experiences in the required data. The purposeful selection of participants was made from the professional nurses with an additional qualification in emergency nursing programme, to offer relevant information about the programme. A list of all students that completed the programme at the specific nursing education institution in the Limpopo province from 2007 to 2013 was drawn and invitation letters to participate in the study were written to them. In non-probability sampling the odds of selecting a particular individual are not known because the researcher does not know the population size or the members of the population (de Vos et al 2011:391). In non-probability sampling the probability that a member of the population will be included in the sample cannot be determined 57  Research design and methods 2016 as the researcher has no way of forecasting or guaranteeing that each element of the population will be represented in the sample (Burns, Grove & Gray 2013:364). Furthermore, some members of the population have little or no chance of being sampled; the researcher selection is based on the sample availability (du Plooy 2009:122). According to Taylor and Francis (2013:190), it is emphasised further that in qualitative research knowledge is dynamic and context dependent and therefore cannot be generalized, multiple voices of participants are described, and that research participants are not randomly but purposively selected in an effort to carefully represent these many voices. The advantage of non-probability sampling is that there are less complications in terms of time and financial expenses, and it enables the researcher to indicate the probability with which sample results deviate in differing degrees from the corresponding population believes (Welman et al 2012:68). This resonates with the view of Polit and Beck (2012:276) that the advantage of non-probability sampling lies in their convenience and economy. The following are limitations of non-probability sampling approach according to Brink et al (2012:139):  Representation of the population is impossible leading to no generalization of study findings  The extent of sampling error cannot be estimated  The researcher bias may be present The following strategies were implemented to overcome the above limitations:  The inclusion criteria were clearly defined to those meeting the criteria.  Participants were engaged in in-depth focus group interviews until saturation was reached to get rich information. The researcher allowed the participants to freely share their experiences and express their views towards the future of the programme without limiting the conversations. 58  Research design and methods 2016 3.3.1.3.1 Purposeful Sampling Purposeful sampling is used in qualitative research for selection of individuals and sites for the study because they can purposefully inform an understanding of the research problem and the central phenomenon in the study (Creswell 2009:178). The purposeful sampling technique is based on the judgment of the researcher regarding participants that are typical or representative of the sample, or who are especially knowledgeable about the study (Brink et al 2012:141). Purposeful sampling, then, was aimed at obtaining insight specific to the programme and not about empirical generalization from a sample to the greater population (LoBiondo- Wood & Haber 2010:224). Purposeful sampling is based on the belief that the researchers’ knowledge about the population can be used to purposefully select sample members who are judged to be typical, representative of the population or particularly knowledgeable about the programme (Polit & Beck 2012:279; de Vos et al 2011:232). The quality of data collected following these approach and technique has a potential to be high, only if participants are willing and able to truthfully give relevant information for the researcher to obtain in-depth understanding of an experience (Burns & Grove 2009:355). Purposive sampling was used as the researchers intent was to specifically target professional nurses trained for an additional qualification in emergency nursing on the basis that the selected participants will provide the necessary data for the study as suggested by Parahoo (2006:268) and Creswell (2014:189). Registered nurses who completed the emergency nursing programme can give valuable inputs pertaining to what works well and the challenges that were met during training with regard to the theoretical and clinical component of the programme. 3.3.1.4 Ethical issues related to sampling Sampling in qualitative research relies heavily on individuals who are willing to participate and able to provide rich accounts of their experiences (Liamputtong 2010:11). The participants were professional nurses who were already trained for the programme in emergency nursing at the Nursing Education Institution in the Limpopo 59  Research design and methods 2016 Province. The participants were made aware of their right to participate in the study without being coerced, and the right to withdraw from the study at any given time. Respect for participants’ autonomy was ensured when obtaining consent and throughout the study. The researcher purposefully selected the students who completed the programme from 2007 to 2013 as they possess valuable experience on the reality of the theoretical and clinical component included in the education and training of the programme. 3.3.1.5 Sample Burns and Grove (2011:51) define a sample as the subset of the population that is selected by the researcher for a study. In view of Polit and Beck (2012:275), a representative sample is needed to ensure that the collected data accurately reflects reality and can be generalized to the population. The sample should be representative of the sampling frame, which ideally is the same as the population, but which often differs due to practical problems relating to the availability of information (Welman et al 2012:55). It is pointed out in Rebar et al (2011:111) that in qualitative research pre-determining the sample is not always possible and as such information from emergent participants is used until data saturation reached. Two strategies are often used to determine sample size in qualitative research. One approach is based on the range or sufficiency, namely, the number of interviews, observations and so on, that is required to capture a representative view of the phenomenon under study. The second approach depends on data saturation or redundancy, namely, the number of people to be interviewed or observed before no new data emerges (de Vos et al 2011:391). Data saturation is defined by Polit and Beck (2012:742) as the collection of qualitative data to the point where a sense of closure to adequate information is attained. Rebar et al (2011:111) explain that saturation of data occurs when data collection becomes repetitive and no new information is emerging or added. For this study data was collected from participants that voluntarily consented to take part in the focus group interviews. The sample size consisted of 20 participants from 60  Research design and methods 2016 the health institutions around the Limpopo Province. Two focus group interviews consisting of 10 participants each were conducted. 3.3.2 Data collection Polit and Beck (2012:367) define data collection as the method used to gather pieces of information required to conduct the research. Data collection in qualitative research is a process whereby information pertaining to a phenomenon is sourced through different techniques which includes, guides, interviews, records, analysis of video and audio recordings, letters, diaries and other documents observations and field notes (Parahoo 2006:65). The research design provides a guideline according to which a selection can be made of which data collection method(s) will be most appropriate to the researcher’s goal and to the qualitative design (de Vos et al 2011:308). Qualitative research relies on methods that can allow researchers into the personal, intimate and private world of participants. Qualitative research utilizes many methods of data collection but the focus group interview method supported by audio-recording and field notes, was the primary data collection method used in this study because it allows the participants to talk about their experiences in their own terms and also provides rich amount of detailed data (Liamputtong 2010:49). 3.3.2.1 Focus group interviews Focus group interviews are described as an interaction between one or more researchers and more than one respondent for the purpose of collecting research data (Parahoo 2006:331).The author is of the opinion that the use of focus groups interviews in evaluation research brings different stakeholders’ views together to clarify conflicting perceptions. Babbie and Mouton (2011:291) describe focus group interviews as interviews with groups of about 6 to 12 people whose opinions and experiences are requested simultaneously to create meaning with regard to a common research inquiry rather than individually. Focus groups are a means of creating better understanding on how people feel or think, and the “focus” is that it involves some kind of collective group activity about the specific programme or service understudy (de Vos et al 2011:360; Holloway & Wheeler 2010:126). 61  Research design and methods 2016 In focus group interviews, sessions are carefully planned and group dynamics can help people to express and clarify their views in ways that are less likely to happen in a one to one interview. Discussions among group members or participants who share a common experience may give a sense of safety and an advantage for accessing rich information (Polit & Beck 2012:728). Focus group members, although sharing common experiences, do not have to know each other (Holloway & Wheeler 2010:129). 3.3.2.1.1 Characteristics of focus group interviews Focus group interviews are characterised by the following elements:  Group participants Members in a focus group usually have similar roles or experiences. Focus groups are characterised by interaction between the participants from which the researchers discover how people think and feel about a particular issue under study rather than general topics. During interaction the groups respond to the interviewer and to each other (Holloway & Wheeler 2010:126). Focus groups provides opportunities for brainstorming and is considered to be highly effective in generating rich data which is further enhanced by the interaction between the group members (Parahoo 2006:333;Polit & Beck 2012:538). A good focus group interview session is emphasised by Speziale and Carpenter (2007:39) as having a potential to learn about both the focus and the group. The participants in this study have all completed training for an additional qualification in the emergency nursing programme from the Nursing education institution in the Limpopo Province from 2009 to 2012.  Group size The size of the focus group depends on the complexity of the study, usually 6 to 12 members in a group. The number of focus groups depends on the needs of the researcher and the demands of the topic (Holloway & Wheeler 2010:127). The size of the group should be adequate enough to allow everyone to participate while still eliciting a range of their thoughts with regard to their experiences (de Vos et al 62  Research design and methods 2016 2011:366). The total number of participants for the study was 20 and two focus groups were conducted. Each group comprised of ten group members and a leader was selected from each group for the purpose of writing down notes on the flip chart.  Environment The environment for a focus group interview should be a non-threatening room, which is important to contain the participants where they can all be heard and be recorded. The sitting arrangement should be comfortable, spatial of a circle or semi- circle (Holloway & Wheeler 2010:130). The location of the focus groups should meet the needs of both the researcher and the participants. The researcher should be able to capture the data in a comfortable environment for the participants as suggested by de Vos et al (2011:371). The location for the interviews was at the learning centre in one of the accredited institutions for training. The prepared area is situated away from the daily activities of the institution and the room is spacious and convenient for the interviews. The participants were seated around the table for better facilitation and communication. The two groups were allocated in separate rooms with enough space between the tables to avoid interruption.  Group facilitator de Vos et al (2011:367) insist that the group facilitator should be experienced with group interviews. The facilitator can either be the researcher or another person with the necessary communication and facilitation skills. The researcher is a nurse educator involved in the education and training of professional nurses for the programme being evaluated. For this reason an experienced independent facilitator (a psychiatric nurse practitioner) with more than 15years of experience in conducting focus group interviews was invited to conduct the group interviews. This will enable the group members to feel free to voice their views, exchanging anecdotes, without feelings of intimidation and power control in the presence of the former nurse educator. 63  Research design and methods 2016  Length of group discussion Most focus groups encompass 1 to 2 hours of discussion although some will extend to an entire afternoon. If focus group sessions are longer, it is necessary to build in breaks to allow participants time to relax and refresh (Burns & Grove 2009:514).The discussions took place from 08h30 to 12h00 with refreshing breaks for tea and snacks in between the sessions. The researchers’ assumptions underlying utilization of the focus group interviews in this study were based on advantages outlined by Burns and Grove (2009:513):  A homogenous group provided participants with freedom to express thoughts, feelings and behaviours related to the practice of the programme.  Participants were regarded as important resources of information about the programme.  The participants were able to report and verbalise their thoughts and feeling freely.  A group dynamics was an advantage in generating authentic information  Group interviews provided more divergent information related to the programme. The utilisation of focus group interviews made it possible to deal with general rather than personal issues as groups came to consensus on the shared data (Preskill & Catsambas 2006:61). Appreciative inquiry process in this focus group interviews guided the stakeholders in the exploration and clarification of their views on the programme in ways that would be less easily accessible in a one to one interview. The participants were also given an opportunity to share their past experiences, wishes, challenges, create innovative ideas and recommendations for the future of the programme. 3.3.2.2 Field Notes Field notes represent a narrative set of written notes intended to paint a picture of a social situation in a more general sense (LoBiondo-Wood & Haber 2010:272). Field notes represent the participant’s efforts to record information and also to synthesize and understand the data (Polit & Beck 2012:548). The authors further explain that 64  Research design and methods 2016 field notes contain a narrative account of what is happening in the field: they serve as the data for analysis. According to de Vos et al (2011:359) field notes are defined as a written account of the things the researcher hears, sees, experiences and thinks in the course of collecting or reflecting on the data obtained during the study. It is vital for the researcher to make full and accurate notes of what goes on during focus group interviews. Memorising during data collection is neither possible nor wise to rely on one’s memory to preserve data for analysis; so it is important that field notes are written as soon as possible during the focus groups interview (de Vos et al 2011:359). In this study a field worker was nominated for taking notes during the appreciative focus group interviews and flip charts were used in each group for the purpose of field notes during data collection. Each group’s leader was responsible for witting down all the information gathered with regard to questions on the interview guide for comparison with the other groups for formulation of categories and themes. 3.3.2.3 Interview guide An interview guide designed by the researcher was used as the data collection instrument. Bryman (2012:712) describe an interview guide as a brief list of memory prompts of areas to be covered during the data collection process. Parahoo (2006:329) state that an interview guide has broad questions or areas but allows the researcher to ask additional questions. In this type of interviews participants are allowed to formulate responses in their own words and are not faced with multi- choice answers to choose from. An independent facilitator was nominated to conduct the focus group interviews for the purpose of avoiding power control on the participants as the researcher is the lecturer in the programme and is known to the participants. The questions were semi structured. The predetermined questions were similar for all the focus groups (view Annexure D). The interview guide was compiled by the researcher based on the 5-D Cycle of Appreciative Inquiry as described in Chapter 1.The independent facilitator was in control of the interview process and the predetermined questions provided the structure to the interview. The facilitator had some flexibility to ask probing questions 65  Research design and methods 2016 according to the interview guide in seeking clarification and obtaining more complete answers rather than uncovering new perspectives. 3.3.2.4 Data collection process This refers to the gathering of information required to address the research problem. The following key steps as suggested by Cooperrider et al (2008:106) in appreciative data collection were followed. 3.3.2.4.1 Identify the participants The identified participants were gathered at a learning centre that is located away from the daily activities of the institution. For the purpose of this study the participants were professional nurses that were in the last month of the academic year and the ones that already completed the programme. The step involves the discovery phase of the 5-D Cycle of Appreciative Inquiry, where the identified participants and the independent facilitator (responsible person for conducting the focus group interviews) were introduced to establish rapport. The overall aim for the programme evaluation was emphasized to create understanding and the importance of the participants’ selection into the study. The independent facilitator was invited to join the group to make the participants free to voice their views in the absence of the researcher to prevent bias. There were two focus groups (with ten participants in each group) with 1hour time allocated for each group for data collection. The format of the inquiry process was also made explicit by the independent facilitator to the participants. 3.3.2.4.2 Craft an engaging appreciative question Appreciative Inquiry is based on the premise that “the art of inquiry moves in the direction of evoking positive images that lead to positive actions...” (Cooperrider et al 2008:106). The change and future of the programme is determined by the direction of the questions asked (Cooperrider et al 2005:88). The authors are of the opinion that the 5-D cycle is a mechanism that allows the researchers to access and mobilise the positive core and in this way the programmes’ positive core becomes the beginning and the end of the inquiry. The focus of inquiry in this study is based 66  Research design and methods 2016 on the 5-D cycle which has its foundation in the positive core within the practice of the programme. 3.3.2.4.3 Develop appreciative interview guide The researcher prepared an interview guide (see Annexure D). The guide consisted of a list of questions to be followed by the independent facilitator during the inquiry process. The independent facilitator provided valuable support to the researcher in order to make the interviews a success before the interview process. The participants were requested to sign a form consenting to participate in the study. All participants were made aware of the utilization of the audiotape and field notes for recording the information, and were also reminded of their right to withdraw from the study at any point without fear of negative consequences. 3.3.2.4.4 Collect and organise the data Participants were asked to get into 2 groups of 10 people. Each group was given 1 hour to respond to interview questions based on the Appreciative Inquiry interview guide (see Annexure D) as presented by the independent facilitator. The interview guide had a list of predetermine semi-structured questions that were drawn up by the researcher based on the 5-D Cycle of Appreciative inquiry as suggested by Reed (2007:123). The same questions were asked from each group and probing questions were used where necessary to obtain rich information. The information was written down on field notes and even audiotaped. The participants were asked to pay close attention when listening and to assume they are listening to a great story to help their interview partners recount more details of the experiences being related. Participants were advised not to interrupt when one participant is responding. The independent facilitator was in control of the groups in terms of time management and organising the data. Time was provided for adequate dialogue, sharing, relationship building and reflection. 3.3.2.5 Conduct the Appreciative Inquiry interviews The way in which the Appreciative Inquiry interviews took place are explained. 67  Research design and methods 2016 3.3.2.5.1 Explaining Appreciative Inquiry An introduction of Appreciative inquiry process to all participants and the main focus of inquiry is an important aspect to put the participants at ease to understand the data collection process (Cooperrider, Whitney & Stavros 2008:113). Appreciative Inquiry was appropriate for the researcher to explain the process to the participants to have better understanding of the approach and to gain rapport. The participation information leaflet was also handed out to participants to facilitate the understanding of the aim of the study. 3.3.2.5.2 Respecting anonymity Anonymity of the information was assured throughout the inquiry process (Cooperrider, Whitney & Stavros 2008:113). Participants’ real names were not used during the process of inquiry. The collected information from the focus groups was compiled into themes and these further ensure anonymity as the information will not be linked to an individual. 3.3.2.5.3 Managing the negatives Good listening skill is required for the facilitator to accommodate different communication patterns and views from all participants (Cooperrider, Whitney &Stavros 2008:113). Data drawn from negative responses was rephrased by the facilitator to allow time for participants to rethink. To archive this, a caring and affirmative spirit was kept by the facilitator at all times. 3.3.2.5.4 Using negative data Appreciative Inquiry starts and ends with appreciating that which gives life to the organization; so the negative data responses were positively approached by the facilitator such that they are turned into positive output (Cooperrider, Whitney & Stavros 2008:114). The information that was negative and not related to the predetermined questions was rephrased into the positive to elicit valuable information that could be used for recommendations for a positive future (Cooperrider et at 2005:96). All related data irrespective of whether it is positive or negative, was used affirmatively. 68  Research design and methods 2016 3.3.2.5.5 Starting with specific stories - the interview rhythm As the focus of this study, it was important for the facilitator to start the inquiry process with storytelling about the peak experiences that are specific to the participants in relation to the theoretical and clinical practice of the programme to create a foundation for probing deeper into each phase of story that is shared (Cooperrider, Whitney & Stavros 2008:114). The facilitator then listened carefully and intensely to learn from all the participants stories as they were unfolded to get into the deeper meaning of the participants views. 3.3.2.5.6 Generalising about life-giving forces An attempt was made by the facilitator to guide the participants to think about what made the peak experience within the programme that they think could be continued (Cooperrider, Whitney &Stavros 2008:115). Affirmative questions were posed to stimulate the participants’ thoughts on a better ideas or options that will benefit the future education and training of the programme. 3.3.2.5.7 Listening for themes-Life-giving factors During the story-telling the life-giving forces that pointed to what worked in the programme were identified and probing utilized to enrich the information (Cooperrider, Whitney & Stavros 2008:115). The identified categories were grouped into themes and were then presented to the focus groups for clarity and verification. The participants were all free and flexible to refine the themes according to their experiences. 3.3.2.5.8 Keeping track of time The participants were made aware of the allocated time for the interviews so the facilitator was keeping track of time for completion of data collection on both focus groups, as interviews have strict schedule (Cooperrider, Whitney & Stavros 2008:115). Scheduled time was followed and respected as agreed with the participants. 69  Research design and methods 2016 3.3.2.5.9 Having fun and being yourself-It’s a conversation An interview is like a normal conversation. Accordingly, the facilitator was humble and patient enough to listen to and value the best in all stories from participants (Cooperrider, Whitney & Stavros 2008:115). All participants were equally valuable and the shared stories brought all new information that is needed to refine the programme. 3.3.2.5.10 Sense making from inquiry data After the focus group interviews the recorded data was reported out of consensus from similar top themes identified from the two focus groups (Preskill & Catsambas 2008:18). The aim of identifying themes is to discover how to do more on what worked well in the practice of the programme (Cooperrider, Whitney & Stavros 2008:117). The audiotapes and field notes were dated and labelled. The values and wishes identified were then shared for sense making and creating a platform for appreciation of others’ ideas of how to fulfil those values within the programme. Anonymity related to the data was assured as no names from the stories and quotes from the interviews will be used or associated with the overall summary or even the report. At the end of the session the main points of view were briefly summarized by the facilitator, to seek verification of the given data from the participants and expression of gratitude was given for participation. For the purpose of this study, projection of findings was summarised by the researcher for analysis. 3.3.2.6 Ethical considerations related to the data collection Holloway and Wheeler (2010:53) asset that ethical issues must be considered in all research, be it quantitative or qualitative. Babbie and Mouton (2011:528) also explain that the science of ethics is concerned with the conduct of research. This knowledge and experience can be transferred to an understanding of ethical issues with regard to the research process (Speziale & Carpenter 2007: 311). The proposal was first reviewed by the research ethical committee of the faculty of health sciences of the university (Annexure: A), the provincial ethical committee of the Department of Health Limpopo province (Annexure: B), and the nursing education institution (Annexure: C), to protect the ethical rights of the participants. 70  Research design and methods 2016 Ethical principles relevant to the conduct of research that were considered and adhered to throughout the study include the principle of respect for persons, the principle of beneficence and the principle of justice (Dhai & McQuoid-Mason 2011: 43; Brink et al 2011:34; Burns & Grove 2011:107). The ethical issues arising from the above principles in data collection are in relation to voluntary participation, informed consent procedures, anonymity and confidentiality towards participants, benefits to participants over risks as well as the respect for the context in which the data is collected. 3.3.2.6.1 The principle of respect for persons The principles adhered to relating respect for persons are described.  Right to self determination Protecting human rights is an important part of nursing research embedded within the principle of respect for persons. Respect for human rights involves the right to self-determination (Burns & Grove 2011:110). The participants in the study were given the respect to determine participation out of their free will.  Autonomy Autonomy incorporates the freedom of individuals’ actions and choices to decide whether or not to participate in research (Bless et al 2013:30). The participants were informed of the nature of the study in the information leaflet and during the introduction before data collection to choose whether to voluntarily participate or not to participate in the study. The participants were informed of their right to withdraw from the study at any time.  Informed consent The participants were invited to participate in the study not coerced to participate. Creswell (2014:96) believes that researchers need to develop an informed consent form for all study participants to give consent prior to participation. All participants participated voluntarily in the study and written consent was obtained prior to data 71  Research design and methods 2016 collection (See Annexure D). The purpose for conducting the study was clearly explained.  The principle of beneficience and mal-beneficience Discomfort and harm in research can be in physical, psychological, emotional or economic (Leedy & Omrod 2013:105; Burns &Grove 2011:118). The researcher should do good and above all do no harm. In this study there was no anticipated physical, psychological and emotional harm. The participants were from the four Limpopo the district areas. The selected data collection venue is the central point to all the districts. Tea and finger lunch were offered to the participants.  Principle of justice The right to fair treatment is based on the ethical principle of justice (Burns & Grove 2011:118). The principle of justice is based on the fact that all people should be treated equally and not discriminated on the basis of race, gender, disability or other characteristic (Brink et al 2012:35). Therefore, the selection of participants was purposeful based on the relevant amount of information required from their experiences in the emergency programme during training.  Privacy and Confidentiality Research studies involving human participants need to respect participants’ right to privacy (Leedy & Omrod 2013:107). The participants were informed of the title of the study, the purpose and type of inquiry to be undertaken so that they have freedom to share information without fear of privacy invasion. The participants were also assured that their identity will not appear on the records to protect their right to privacy and confidentiality. Participants were reassured that information in the report would not identify them personally. Privacy and anonymity of the collected data were guaranteed. The information will be kept in a locked file when not in use, with access only to the researcher. The participants’ rights to anonymity, confidentiality and privacy concerning all information were maintained throughout the study. 72  Research design and methods 2016 Forrester (2010:112) suggests that qualitative researchers can never promise complete confidentiality but should rather clarify what will be done with the data and how participants’ identity will be protected. Hence during the focus group interviews participants were not addressed using their names but pseudonyms. Participants were seated around a table and requested to identify themselves according to their seating arrangement around the table. The researcher is the instrument and the main source of data collection (Holloway & Wheeler 2010:9). In this study, the researcher is known to the participants. However, the researchers’ involvement during data collection was replaced by a neutral person, an independent facilitator to avoid power control. The independent facilitator is a psychiatric nurse who is well conversant with Appreciative Inquiry approach and skilled in communication. The researchers’ moral behaviour involves the researcher as a person who has to be sensitive, committed to honesty and integrity and avoiding deception about the nature of the study, therefore data collection and recording was done as honestly as possible. 3.3.3 Data analysis Data analysis in qualitative research is the systematic organisation and synthesis of research data (Polit & Beck 2012:725). According to de Vos et al (2011:397) qualitative data analysis must be systematic, sequential, verifiable and continuous and is improved by feedback. In addition, Speziale and Carpenter (2007:96) state that data analysis requires researchers to be fully immersed in the data for meaningful descriptions and better understanding of the study. For this study the following steps were used as proposed by Tesch (1992:92) and described in Creswell (2014:198). The steps of data analysis are as follows: 3.3.3.1 Step 1: Get a sense of the whole This step was important to establish the background for the study. The researcher here immerses themselves in the data. The process of data analysis started when the researcher listened to the audiotape and read all the data that was been transcribed. Data collected from the participants through the appreciative inquiry 73  Research design and methods 2016 interview guide was carefully read and examined to get a sense of the presented information until a clear picture of the data was formulated. 3.3.3.2 Step 2: Selection of a topic When the researcher was satisfied that all the data was accessible, then the information from each focus group interview was examined and notes made regarding the underlying meaning of the projected information in order to select topics. All thoughts related to the topics were written down. 3.3.3.3 Step 3: Cluster and compare the topics The researcher drew up a list of all the identified topics for the purpose of comparing data. This process was continued throughout the data until all the themes, subthemes, and categories were revealed. Similar ideas from each focus group were grouped into similar topics and clustered together. A descriptive statement was then formulated by combining all the themes together. 3.3.3.4 Step 4: Review the data The data was transcribed and reviewed until data saturation was reached. A code for each of the major topics from the collected data was established and coded into appropriate topics to identify if new categories and codes are emerging. 3.3.3.5 Step 5: Refine the data The best descriptive wording was determined for the topics that related to each other. Topics were grouped into categories, written down and interrelationships identified. Emerging topics identified during the process were put aside for consideration. 3.3.3.6 Step 6: Alphabetise the categories A decision was made on abbreviation for each category and then arranged in alphabetical order. 74  Research design and methods 2016 3.3.3.7 Step 7: Preliminary analysis The data for each category was assembled and summarized. Subsequent to that, careful attention was paid to the generalisability within the content and appropriateness with regard to the appreciative inquiry questions as suggested on the interview guide. Preliminary data analysis was then performed. 3.3.3.8 Step 8: Recode existing data Existing data was recorded whenever necessary. Themes and sub-themes were verified. Data collected was then transcribed verbatim and analyzed. After data analysis the independent facilitator and researcher met to have consensus discussions regarding themes and sub-themes identified. The purpose for this study was to find meaningful descriptions of the stakeholders’ experiences with the aim of refining the programme. The full data analyses together with the findings are described in Chapter 4. 3.4 TRUSTWORTHINESS Holloway and Wheeler (2010:302) refer to trustworthiness as the methodological soundness and adequacy of a study. Trustworthiness is an important aspect of clarifying the notion of objectivity in qualitative research (Babbie & Mouton 2011:277). According to Polit and Beck (2012:745) trustworthiness is defined as the degree of confidence qualitative a researcher has in their collected data. Trustworthiness is assessed using the criteria of credibility, transferability, dependability, conformability and authenticity. The utilisation of these criteria for trustworthiness is based on Lincoln and Gubas’ framework of 1985. Brink et al (2012:172) explain trustworthiness as a way of ensuring data quality or rigour in qualitative research and propose that it should be used proactively throughout the study to manage the research. The strategies that were applied to ensure trustworthiness are as follows: 3.4.1 Credibility According to Polit and Beck (2012:585) credibility refers to confidence in the ‘truth value’ of the data and findings. Credibility in research requires that the participants 75  Research design and methods 2016 recognise the meaning that they give to a particular situation and the truth of the findings in their own social context (Holloway & Wheeler 2010:303). Qualitative researchers should strive to enhance the credibility of the study and take steps to convey this to the external reader (Polit & Beck 2012:585). ‘Truth value’ represents the accuracy between the participants’ views and the way in which a facilitator makes representation of their information. Credibility in this study was achieved through the following procedures: 3.4.1.1 Prolonged engagement Prolonged engagement in the field includes building trust with participants (Creswell 2009:207). Contact with participants was made prior to the interviews to build rapport. Prolonged engagement promotes the researcher’s in-depth understanding of the elements of the study such as they are related by the participants. The researcher is a nurse educator involved in the education and training in the emergency nursing programme for the past 6 years. The researcher is familiar with the participants as former students; therefore, rapport was made easy during the introduction session. Provision of adequate time was made with the independent facilitator for building a trusting relationship and eliminating the distractions that might be created. 3.4.1.2 Data triangulation The use of different data collection sources within the context of the study is the best way to elicit the various and divergent construction of reality (Babbie & Mouton 2011:277). The convergence of multiple sources of data ensures that the research contains richness, depth, complexity and rigour. In this study methodological triangulation of data was achieved by combining the focus group interviews with descriptive and reflective filed notes and utilisation of the audiotape during the interview process. The utilisation of semi-structured interviews in this study allowed flexibility and openness for participants to give adequate data. Data was collected from participants in two focus groups who were trained in different years from 2010 to 2013 to build a coherent justification for themes and then compared with available literature to obtain diverse and rich information on the study to validate the findings (Creswell 2014:201). 76  Research design and methods 2016 3.4.1.3 Referential adequacy This refers to the materials or equipment used to capture the data (Babbie & Mouton 2011:277). The participants were initially informed of the data collection methods during the preparation phase. An audiotape was used to record data and emerging themes from the inquiry were also given cognisance. Data was also captured on field notes by the independent facilitator. Verbatim transcription of the data was done before data analysis to ensure referential adequacy. 3.4.1.4 Member checking Member checking involves providing the participants with feedback to check the data, analysis, the interpretation and conclusions to verify or judge the accuracy and credibility of the account (Polit & Beck 2012:591; Babbie & Mouton 2011:277; Creswell 2009:208). The purposes of member checking are outlined by Holloway and Wheeler (2010:305) as follows:  Find out whether the reality of the participants’ information is presented by rereading of the data for confirmation.  Provide opportunities for the participants to correct or change the errors that were made.  Assess the researchers understanding, meaning and interpretation of the data.  Give an opportunity for the participants to challenge each other’s ideas and the interpretation given by the researcher. To ensure credibility in this study the description of the information was verified with participants for validation to provide an opportunity for clarity. Through the focus group interviews information was checked with participants on the understanding of the data by repeating and paraphrasing the participants’ words. 3.4.2 Transferability Polit and Beck (2012:585) describe transferability as an extent to which findings from the data can be transferred to other settings or groups. Related to this, Holloway & Wheeler (2010:303) are of the opinion that the knowledge acquired in one context will be relevant in another, especially for those who carry out the same research. 77  Research design and methods 2016 3.4.2.1 Purposeful Sampling The participants’ selection in purposeful sampling is done based on the value of the information that the participants possess (Babbie & Mouton 2011:277). Transferability was first enhanced by purposeful selection of participants with adequate knowledge related to the study. All participants were trained in the Emergency nursing programme offered by the NEI in the Limpopo province. 3.4.2.2 Thick description In qualitative studies transferability means detailed description of the data collection process, context, description of the analysis process and reporting. The description needs to be explicitly explained to allow evaluation of quality and judgment about transferability to be made by the reader (Babbie & Mouton 2011:277). In this study the description of the data collection and analysis process were explicitly explained during the data collection process. This was also confirmed with participants before the final data analysis so that the reader is able to understand the process involved in the context and allow for replication of the study in similar situations. 3.4.3 Dependability Holloway and Wheeler (2010:302) believe that if the findings of a study are to be dependable, they should be consistent and accurate. The dependability of qualitative data refers to the stability or reliability of data over time and over conditions (Polit & Beck 2012:585). The description of the data was written in such a manner that another researcher would be able to follow the proceedings of the study. 3.4.4 Confirmability Confirmability is described by Babbie and Mouton (2011:278) as the degree to which the findings are the product of the focus of the inquiry and not the biases imposed by the researcher. Conformability refers to objectivity that is the potential for congruence between two or more independent people about the data accuracy, relevancy or meaning (Polit & Beck 2012:585). In addition, de Vos et al (2011:421) refer to confirmability as the final construct which captures the traditional concepts of objectivity. 78  Research design and methods 2016 Conformability was enhanced by involving an independent facilitator not connected to the programme to confirm that the interpretations are a true reflection of the information as shared by the participants. Triangulation of the data was also done by obtaining data from one focus group and extrapolating it to the other for accuracy to confirm the meaning for the data as implied by the participants. Field notes from the transcribed data were kept to compare to the audiotape data. 3.4.5 Authenticity Authenticity occurs when the researcher faithfully and fairly reveals the range of different realities as experienced by the participants (Polit &Beck 2012:585; Brink et al 2012:173 and Holloway & Wheeler 2010:304). The genuineness of the research data emerges when it conveys the feelings of the participants to invite the readers into the description of the lived stories (Botma, Greeff, Mulaudzi & Wright: 234). Information given by the participants was carefully interpreted to reveal the same meaning as related to assure that the interpretation is grounded within the data. 3.5 CONTEXT According to Holloway and Wheeler (2010:41), context includes the environment and the conditions in which the study takes place as well as the culture and attitudes of the participants that permeate the setting. The research study was conducted at a health institution with professional nurses who are trained for an additional qualification in Emergency nursing programme offered by a Nursing Education Institution in the Limpopo province. The views of these professional nurses are specific to the context related to the practice of the programme in the Nursing Education Institution in which the researcher practices. 3.6 CONCLUSION In this chapter the researcher provided a detailed description of the research methodology that was applied in the study. In chapter 4 an in-depth overview of the research findings, procedures applied during data analysis and interpretation will be provided. 79  Analysis, presentation and description of the research findings 2016 CHAPTER 4: ANALYSIS, PRESENTATION AND DESCRIPTION OF THE RESEARCH FINDINGS 4.1 INTRODUCTION In Chapter 3 the research design and methods of this study were discussed in depth. Chapter 4 focuses on the research findings obtained from the collected data as well as supportive literature. The chapter presents data management and analysis, research results and overview of the research findings. 4.2 DATA MANAGEMENT AND ANALYSIS Data management and organisation ensure data analysis. Data analysis in qualitative research is described by Polit and Beck (2012:557) as the systematic organisation and synthesis of research data in order to gain information pertinent to a given research question. Burns and Grove (2011:93) and Brink, van der Walt & van Rensburg 2012:193) point out that qualitative data analysis occurs simultaneously with data collection which implies that the researcher attempt to gather, manage and interpret data at the same time. In addition, Speziale and Carpenter (2007:96) believe that data analysis requires researchers to be fully immersed in the data for meaningful descriptions and better understanding of the study. The researchers’ aim is to ensure that the analysis is presented in a manner that the participants as well as other readers will get sufficient and appropriate information described from the transcript and field notes (Polit & Beck 2012:557). 4.2.1 Data management Data was collected by means of two focus group interviews with 20 participants of whom seven were males and thirteen females with the aim to evaluate the emergency nursing programme offered at the NEI in the Limpopo province, through qualitative, exploratory descriptive design. The participants were all trained in emergency nursing offered by the Limpopo College of nursing in various academic years of training from 2007 to 2013. Data was collected by an independent facilitator using an interview guide (View Annexure D) with ten questions: five on the theoretical component and 80  Analysis, presentation and description of the research findings 2016 five on the clinical component. The participants were requested to sign the informed consent and to fill in the required demographic data prior to data collection. The interviews were audio taped and field notes written. The independent facilitator also transcribed the audio taped interviews and stored them on a USB flash disk. 4.2.2 Data analysis Data was analysed according to Tesch’s (1992:92) method of data analysis. Data analysis was described in detail in Chapter 3 (see Section 3.3.3.).The researcher listened to the audiotape and read through the transcribed data to ensure that no data was lost. The researcher then immersed herself in the transcribed data by reading and re-reading until she was familiar with the data (Bless, Higson-Smith & Sithole 2013:342). The transcribed data was then coded and similar units were grouped together into themes, from which categories and subcategories emerged. 4.3 RESEARCH RESULTS The research results are discussed. 4.3.1 Sample characteristics The sample consisted of 20 professional nurses who were trained for emergency nursing from 2007 to 2013, seven of whom were males and thirteen were females. The females were from the age of 28 to 52 years whilst the males were from the age of 29 to 32 years .The participants’ nursing qualifications were from enrolled nursing and the highest qualification was a B-Hons degree. The health districts represented were six from Capricorn, six from Waterberg, 2 from Vhembe, 3 from Mopani and 1 from Mpumalanga. 4.3.2 Results The results were organised in relation to the objectives that directed the study (see Section 1.4.2.) on the theoretical and clinical aspects of the programme. The research results will be discussed in terms of the themes, related categories and sub categories from Section 4.3.1 to 4.3.2. A summary of the themes, related categories and sub- categories is given in Table 4.1. Table 4.1: Summary of themes, categories and subcategories 81  Analysis, presentation and description of the research findings 2016 THEME CATEGORY SUBCATEGORY 4.3.2.1 EXPANDING OUR Positive theoretical Increased knowledge KNOWLEDGE AND experiences Curriculum content UNDERSTANDING Motivation to learn Pre-registration exposure period Nurse Educators characteristics Shortage of resources Shortage of nurse educators Shortage of classrooms Study materials Orientation Acquisition of theoretical Teaching and learning learning strategies Feedback Nurse Educators attitude towards students Continuous professional development for Nurse Educators Rules and regulations regarding nurse training. 4.3.2.2 DELIVERING THE Positive clinical Pre-registration clinical PRACTICE IN THE experiences exposure CLINICAL SETTING Relationship with clinical staff Competency in clinical practice Interprofessional teamwork Negative clinical Inadequate exposure period experiences Shortage of clinical personnel. Students as workforce Anxiety and frustration Theory and practice gap Clinical placement at Emergency Medical Services (EMS) Clinical Support Clinical supervision Mentoring, Preceptorship and Clinical facilitation Acquisition of clinical skills Simulation Partnership with other health institutions Scope of practice Students residential area Two main themes emerged from the data analysis, six categories under each theme and related subcategories. The themes, categories and subcategories will be discussed in depth in Sections 4.3.2.1. to 4.3.2.2. 82  Analysis, presentation and description of the research findings 2016 Tell me a story about the best theoretical experience that you had as a student in the education and training for the emergency programme 4.3.2.1 Theme 1: Expanding our knowledge and understanding The first main theme that emerged from the data was the theoretical aspect of the programme. The participants indicated that the theoretical aspect was interesting as the content was quite challenging and therefore stimulated critical thinking through the process of learning. The participants were motivated to improve their professional level of understanding and development for better emergency nursing care practice. “… I [the participant] found it very interesting and quite engaging in manner that the content or the curriculum itself is prepared to extensively expand our understanding on the content of theory…” “…I [the participant] found it very well prepared and quite sufficient ,stimulated critical thinking in order to enrich a person (the student) to be sufficient as a trauma nurse..” “...I think the programme brought much improvement on how to manage the criticall ill in the emergency and critical care units you were always compelled to critically think and analyse before you attack a situation...” Discussion: The responses from the participants are consistent with the study conducted by Gilbels, O’Connell, Dalton-O’Connor and O’Donovan (2009:67) on evaluation of the impact of post registration nursing and midwifery education on practice, it was clear from the result that the students benefited from post registration programmes in relation to change in attitudes, perceptions and knowledge and skills acquisition and applying the new qualification to their field of practice. Critical thinking is regarded as the disciplined, purposeful and reflective examination of evidence in order to make informed judgement on one’s own values and actions (Hughes & Quinn 2013:539). Critical thinking is a process of thinking that engages the individual’s intellect and enables the nurse to function as a knowledgeable performer who selects, combines, judges and uses information in order to proceed in a professional manner (Price & Harrington 2010:8). It was revealed in Marcin and 83  Analysis, presentation and description of the research findings 2016 Pearson (2014:5) that the development of critical thinking skills results in a degree of discomfort as a result of the students’ engagement with new knowledge and ways of thinking. The authors further emphasised that the utilisation of Appreciative inquiry in this study enhanced the outcome of the participants’ learning experience by providing positively orientated development strategy that can be employed later in their careers in an organisational leadership role context. Six categories emerged from the theme ‘theoretical aspect’ each one of them will be individually discussed. 4.3.2.1.1 Category: Positive theoretical experiences Positive theoretical experiences were related by the participants in the study as valuable to their training. The participants reported increased confidence from completing the programme as well as feeling more assertive with increased knowledge and skills to challenge the practice. The confidence attained from the training was regarded by the participants as instrumental to career advancement. The increase in knowledge and skills was believed to have an influence on increased credibility and autonomy in the practice setting and an increase in job satisfaction. The identified positive experiences included increased knowledge and the relevant curriculum content. “… I [the participant] can say the course is of high standard, equips one with knowledge to can competently work in all the health care units where critically ill patients are managed…” “…I [the participant] found it very well prepared and quite sufficient to enrich person in order to be sufficient as a trauma nurse in the clinical practice...” Discussion: Appreciative Inquiry holds the potential for inspired and positive change and involves a collaborative search for those strengths and life giving forces which are found in individuals, groups and or institutions (Bushe 2007:32). The positive sharing of experiences creates a world of reality on the practice of the programme and is 84  Analysis, presentation and description of the research findings 2016 supported by the constructionist principle which postulates that words create the world (Edwards & Edwards 2012:306). The process of meaningful academic learning is influenced by the curriculum and health care context in which the students are clinically placed (Millberg, Berg, Bjork- Bramberg, Nordstrom & Ohlen 2014:716). The authors further emphasise that these meaningful academic learning motivates students into their professional roles based on the foundational knowledge and skills acquired during training and contributes to professional confidence.  Sub-Category: Increased knowledge The participants’ revealed that they initially lacked confidence in their own intellectual abilities initially during the first block period and experienced doubt trying to learn in a new way. Lack of confidence was particularly noticeable as the participants indicated that they struggled with self-directed learning, which required individual effort to reach the expected outcome, however improved confidence as they progressed through the programme was noticed. Participants positively perceived that by undertaking new learning approaches, they had opportunity to foster academic and cognitive learning skills, increased knowledge acquisition and also believed that the intensity of the programme encouraged them to increase their responsibility and autonomy for their independent learning. The participants agreed that acquired knowledge was regularly used to improve the quality of care to individuals who required emergency care at the peripheral hospitals where they are working. All the participants affirmed that exposure to the programme engaged them in acquisition of new knowledge and skills for the application of quality care. “…this course is very much interesting and is also giving us [the participants] more knowledge because before we [the participants] came to this course I [the participant] thought maybe people who are having trauma and general nursing are just the same but when I [the participant] arrived here I realised that this course is 85  Analysis, presentation and description of the research findings 2016 more informative... very challenging, because when I came here I thought I was knowledgeable ...looking at my experience…” “...when we[the participants] started with basic course you find that we don’t know more about the conditions but since we came to this course then we understand it more ...like interpretation of electrocardiogram (ECG)...I [the participant ] think it helps a lot in understanding the basic part...” Discussion: According to the South African Nursing Education Training Standards (2005:35), the Nursing Education Institutions must be able to produce students with clinical reasoning, problem solving, and critical analytical and reflective thinking skills in the programmes that are run in the institutions to improve the quality of care to the community. Furthermore the Commission of European Communities (2007:3) places greater emphasis on investment and commitment towards effective and efficient education for purposes of increasing knowledge in educational institutions. The responses related to increased knowledge are supported by Ng, Tuckett, Fox- Young and Kain (2013:168) in a study on exploration of registered nurses’ attitude towards post-graduate education in Australia. The participants in this study emphasized confidence over their improved knowledge, skills and the development of correlation between knowledge and quality of care. Knowledge makes sense only if the learner understands its application value (Muller 2011:347).  Sub-Category: Curriculum content The participants mentioned that the curriculum content for the programme is adequate and relevant to the complexity of the programme. The participants ranked the programme as being of a high standard that enabled the professional nurse to practice independently and responsibly based on the amount of knowledge gained in assessment, diagnosing and implementation of knowledge on emergency management. “...I [the participant] think the content itself was very relevant…” “...I [the participant] found the curriculum very well prepared and quite sufficient to enrich a person in order to be sufficient as a trauma nurse...” 86  Analysis, presentation and description of the research findings 2016 “...when we [the participants] were doing aviation physiology the detailed explanation one gets to understand because that is the most interesting part obviously when we are talking about aviation that is where we focussed on a group discussion...” “...I [the participant] found it very interesting and quite engaging in a manner that the content or the curriculum itself is prepared to extensively expand our understanding on the content of theory...” Discussion: The concept curriculum has its origin in the Latin word curere, which means “to run” and it refers to a track or a course to be run (Bruce et al., 2010: 166). A curriculum is a plan or design upon which the education of students is based. It is a scientific, accountable, written document containing selected, ordered and evaluated content (Meyer & van Niekerk 2009:49). The curriculum design of the programme should be relevant to the specific competencies required for quality nursing care in accordance with the needs of the students (Muller 2011:336). It is this responsiveness to needs that prompts Armstrong, Geyer, Mngomezulu, Potgieter and Subedar (2011:175) to hold the view that the content of a programme is an important aspect of quality education and therefore should be relevant to the needs of the community it serves to equip the students with relevant information. A nursing curriculum should identify the content, knowledge and competencies expected of students throughout the nursing programme (Finkelman & Kenner 2013:130). A programme should be evaluated as guided by the regulating body for rigor as well as to determine if the content and practice is meaningful and relevant to all stakeholders including the students, the faculty and the community which is served by that institution (Pross 2009 :561). Elaborate on the aspects of theory that are valuable for success in the programme? 4.3.2.1.2 Category: Motivation to learn The will and curiosity from the participants to enroll for study in the programme was developed from observations on how lives were saved in the emergency unit, the 87  Analysis, presentation and description of the research findings 2016 teaching role that the professional nursing and medical personnel took upon themselves every day to impart knowledge to the students during in-service training and performance of emergency procedures in the unit. Exposure into the programme content brought advanced knowledge to the participants to ease the complex information that was required during rounds and presentation of cases with medical practitioners. The participants identified pre-registration exposure period, students’ selection criteria and the nurse educators’ characteristic as aspects that motivated their training and learning in the programme. During pre-registration exposure the learners engaged with clinical staff that was ready to teach, and upon registration they met nurse educators who were open and friendly to students. Each of the three components will be discussed. ”... Looking at the other students who are already in the course you look at them what they are doing and then you start to have an interest...” “... We [the participants] are able to interact on a more serious level with the general practitioners because I [the participant] found that during rounds when doctors are discussing something the level of understanding is the same... “...I [the participant] want to appreciate on the early morning lectures between seven and eight in the emergency unit that I found to be very challenging to keep on preparing … I found it very helpful because some of the things you [the participant] will just write the test without even going to the books by just remembering what they [the clinical personnel] taught …so they must keep it up as knowledge is updated every day...”. Discussion: The motivation of an individual to learn depends on the emotional state concerning the desire to perform the task, feelings towards task performance as well as the volition or the ability to make independent decisions without external pressures being placed on an individual to make those decisions (Muller 2011 :181). Motivated students show better self-regulatory control with the outcome influencing future motivation. It is indicated by McQuillan, Makic and Whalen (2009:16) that the broad spectrum of required knowledge in emergency care has attracted nurses to accept the 88  Analysis, presentation and description of the research findings 2016 challenge of contributing the integral components of a multidimensional and holistic focus in caring for trauma and emergency medical patients. Parboteeah (2010:2) avers that lecturers should think of themselves as active socializing agents that are skilled to inspire students to study in their field of choice. Students in nursing are motivated because they want to be able to solve their work- related problems or because they want to increase an area of competence they already have (Booyens 2011:386). Students as nurses are in most instances always internally motivated, but they sometimes need extrinsic motivation, which is found in the environmental conditions that they find themselves in like positive encouragement and support (Cherry & Jacob 2014:298). Motivators that are important for progress in learning include a need to feel competent, to be self-determining, fully functioning, advanced, self-actualising to grow in the advanced practice (Booyens 2011:458). Positive reception from colleagues motivated the professionals to complete the programme and continue with academic learning afterwards in a study by Millberg, Berg, Bjork-Bramberg, Nordstrom and Ohlen (2014:718) on academic learning for specialist nurses.  Sub-category: Nurse Educators characteristics The participants in this study portray the Nurse Educators as knowledgeable, supportive and passionate. Most of the participants described the behaviour of nurse educators as positive with regard to students learning problems, as they were approachable. “...I [the participant] can say they (nurse educators) are there for us [the participants] even when they are at home if you call them having a question they are always there for you...” “...Ever since I [the participant] came the nurse educators are friendly, they are at our standard...” “... if little information was given by the students during discussion the nurse educators are able to give more than we have...” 89  Analysis, presentation and description of the research findings 2016 “...when we[the participants] were having group discussion and presentations, the positive thing I [ the participant] liked was the facilitators were having more insight into the content for discussion so if students have problems or you don’t reach (ke gore) meaning being knowledgeable in another way they can correct us and give us light, we were very satisfied...”. Discussion: The nurse educator is the most important resource in the education of nurses and the most influential factor in determining effectiveness in the learning situation for training and education (Armstrong et al 2011:189). The nurse educator is a subject expert who possesses the necessary knowledge, skills, attitudes and values to facilitate learning therefore should maintain the principles of positive communication skills, mutual respect and unconditional acceptance of the learner (Muller 2011:346). It is emphasised by Erasmus, Loedolff, Mda and Nel (2013:222) that a friendly, open atmosphere reduces stress and anxiety, brings students close to the educator and creates trust between them. Similarly, Dapremont (2011:258) believes that support and encouragement from the education faculty members are essential for improved student performance and motivation to complete the programme. Good delivery of learning results depends on whether the students understand the educator who delivers the training. Obversely, there can be a negative impact if the educator is not adequately skilled (Harward &Taylor 2014:76). Tell me about the challenges that you met in theoretical learning 4.3.2.1.3 Category: Shortage of resources The participants expressed concern on the shortage of resources required for smooth running of the programme. Resources discussed under this category include nurse educators, classrooms and study materials. The sub-categories related to the shortage of resources will be discussed below. 90  Analysis, presentation and description of the research findings 2016 “...The Department of Health need to take this programme serious because currently even with the manpower I [the participant] am not happy with the manpower, they[ the Department of Health] might not admit it but then it becomes a challenge especially when there is overlapping of nurse educators from one subject to the other because of lack of manpower...” “... we [the participants] don’t even have recognised classes, we are training specialists who don’t even have anywhere to attend classes, some days we have to wait outside the attending areas until the doctors meetings are over...depending on how long the meeting will last the classes will not take place...” Discussion: Learning takes place when a student is provided with a variety of learning resources that offer exposure to other opinions that assist in promotion of learning, like having adequate structure, nurse educators and study material (Armstrong et al 2011:156). The accredited Nursing Education Institutions are expected to have accessible and relevant physical facilities (Nursing Education and Training Standards 2005:24).  Sub-category: Shortage of Nurse Educators In the findings for this study, the participants reported that shortage of staff was a major challenge that crippled the efficient theoretical learning and rendering of healthcare service and that also impacted negatively on students practical learning during clinical placements. The participants’ verbalised shortage of lecturers as a problem which delays learning as the year plan is sometimes not followed and reallocation of tests had to be done. The college utilises the block system where in there are four blocks per academic year. There must be one test written per subject in each block. The participants wish was for the programme to have additional Nurse Educators to share the workload of the three subjects namely; Nursing dynamics, Capita Selecta and Speciality. “...if it is about accompaniment if the nurse educator is marking the scripts yet did not accompany us [the participants] I think it is a serious problem...” “...During the course one of the nurse educators was sick there was a situation where we didn’t have anyone to facilitate. So I [the participant] don’t know maybe if 91  Analysis, presentation and description of the research findings 2016 they[the nursing education institution] can have two nurse educators per subject so if one is sick one can come and help...” “...The year plan is not followed...sometimes because of unforeseen circumstances the students must cover the curriculum content before they write the test and then you will need to do the catch up which means they have to stick to the year programme the student are going to have a congestion of work to write a test which you were supposed to have written maybe with the last block...” Discussion: Nursing shortage is considered as a global major barrier that affects the nurses’ productivity, competency and their commitment to the health care organisation that they work for (Jooste & Jasper 2012:59; Mokoka, Oosthuizen & Ehlers 2010: 9). The study by Bhat, Giri and Kiokala (2010: 1) revealed that shortage of health workers is a massive problem globally but most intensely in developing countries. Furthermore, Vance (2011: 9) states that globally, nursing shortages are complex and projected to intensify in future due to an ageing workforce, declining number of enrolments at nursing schools and the perception that nursing offers fewer prospects than other careers. It is mentioned in studies conducted by Mokoka et al (2010:9) and de Beer, Brysiewicz and Bhengu (2011:8) that South Africa is also experiencing a serious shortage of nurses which has to be addressed to prevent the crises in health care services. Smith (2010:2) purports that the aging of registered nurses in the workforce is one of the causes of shortage of nurses in the United States. South Africa has a shortage of nursing staff that is due to emigration and nurses withdrawing from active practice (Smith 2010:19). The Nursing Education and Training Standards policy (2005:22) states that formal institutional human resource policy must be in place in the Nursing Education Institution. The staff establishment size and composition must be sufficient to provide teaching and guidance to ensure student progress and practice readiness. Geyer (2010:88) states that quality nurse education is impossible if the quality and quantity of nurse educators is inadequate. Armstrong et al. (2011:88) state that without sufficient educators in the system, educational programmes cannot be offered at the required level of quality. Students find it difficult to integrate theory and practice 92  Analysis, presentation and description of the research findings 2016 because of the lack of resources and the unavailability of nurse educators to support them in the clinical area (Yara & Otieno 2010:126 &131).  Sub-category: Classrooms and desks The participants reported that there is no classroom available for the emergency programme in the college. The classrooms that are available are shared among the medical doctors and the post-basic students and preference is always given to the medical doctors. It is stated that during block times the students are removed from classes to give room for the medical doctors to hold meetings, students are made to wait for the meeting to end if the nurse lecturer does not find a room to accommodate them. “...There are no lecture rooms here in Pietersburg so they [the nursing education institution] must sort out those issues...” . “... I don’t know whether I would be off line but let me just (facilitator “no no remember there are no right or wrong answers no ins and out of line”)...okay we [the participants] have a challenge in terms of meeting as a trauma class we don’t have a trauma class actually, we are being tortured, to attend a programme without a class is a torture...” . “...There is an issue in Sovenga Campus that sometimes when you are in class they [the classroom organiser] come to take the your table saying its for writing examinations....” Discussion: According to the Nursing Education and Training Standards (2005:31) the Nursing Education Institutions must be able to provide classrooms and clinical learning environment that delivers the knowledge and skills required to meet the needs of the students. The psychological environment of the classrooms is of paramount importance to learning as these can be perceived by students as places where their lack of ability may be exposed therefore creating a psychologically safe atmosphere in the classroom will stimulate active participation (Hudges & Quinn 2013: 20). 93  Analysis, presentation and description of the research findings 2016  Sub-category: Study materials The participants in the programme experienced late provision of study guides and workbooks at the beginning of the programme and this experience was seen as a delay in studying the expected learning objectives and completion of clinical records. It was indicated that timeous provision of study guides and workbooks at the beginning of the programme will ease the students’ frustration with regard to the expectations on the theoretical content and performing expected procedures in the clinical workbook. “...The other problem is that we [the participants] did not receive work books on time...” “...before we [the participants] start with the course the nurse educators must tell us what is expected of the students in the study guide,....I [the participant] think this information must be given to students before registration in the programme...” Discussion: A study guide signposts the direction for the student to follow concerning what to learn, how to learn, and what will be the indication that the students have to master in that particular content (Harrison 2008:13; Meyer & van Niekerk 2009:99). The authors further indicate that a study guide determines an overall perspective of what is expected on the students in a particular subject for a programme on completion of each study module. Elaborate on the aspects of theory that are valuable for the success in the programme? 4.3.2.1.4 Category: Orientation The participants reiterated the importance of being orientated into the expectations of the programme through the pre-registration package, where in objectives for each module will be stated so that the students enter the programme well prepared. The participants even suggested that there should be a form of formalised evaluation of the pre-package content to test the students’ level of understanding. The results for the pre-package should then be utilised for entry requirement into the programme. 94  Analysis, presentation and description of the research findings 2016 The participants put forth the ideas and changes which when implemented will serve to sustain the positive transformation of the programme. The findings speculate that formalised pre-registration package can improve the students’ performance and also guide college management with the selection of students for enrolment into the programme. “... I think before anyone can come to the programme they must get a pre-package so that they can get aquinted to the content and be tested.It will sort of give guidance of what is expected...” “... the pre-package must be part of the selection criteria...” Discussion: It is an advantage to the emergency nurse to have significant experience in emergency and critical care nursing before caring for the patients whose injuries may involve multiple body systems whose physiologic responses are often complex (McQuillan, Makic & Whalen 2009:136). The students in adult learning are problem and task orientated therefore requires orientation to stimulate interest in to the theoretical content of the programme for application to appropriate real life situations(Muller 2011:331). Elaborate on the aspects of theory that are valuable for the success of the programme? 4.3.2.1.5 Category: Acquisition of theoretical knowledge It was reflected in the participants’ response that some students were not confident enough to learn on their own using different learning strategies. As evidenced by the responses, the participants lacked information on learning that was assumed to be in place from the previous basic training as they indicated that it took them long to cash up with the expected pace. Some of the participants’ felt that self-study and discussion that was recommended by the Nurse Educators to focus on the students to improve the ability to do the work on their own was not well accepted. According to the participants’ profile, some of the participants had a maximum period of ten years not exposed to any studies, and these had a negative effect on validating 95  Analysis, presentation and description of the research findings 2016 individual learning, practice and competence in expected nursing practice. The responses also indicated that the students experienced different levels of frustration at the beginning of the programme with regard to the existing ideas they had on knowledge and skills practice which were challenged by the expected objectives and the facilitation strategies that were utilised for the programme. “...you [the participants] will find that the specific content is assumed to be in place and you find that you have done anatomy and physiology maybe 10 years ago now you have to study and remind yourself...” “...you [the participants] get interaction with the staff that is allocated in the clinical areas, but it is just that they will teach one or two things that are practically based, but the theory part you don’t get training...” “... I [the participant] think it will be much better if sometimes like neurological system maybe after the lecturer has given us the theory, invite an expert like maybe a neurosurgeon to come sort of iron some of the things because they are experts in that field to reinforce the information....” “...I [the participant] remember the nurse educator did invite the cardiologist but the planned schedule was not respected...” Discussion: Nurses who care for patients throughout the cycle of trauma and emergency care must possess a strong pathophysiologic knowledge base on vital body systems (McQuillan, Makic & Whalen 2009:136). The authors believe that sufficient knowledge is needed to assess the patients and to plan and direct appropriate care in each of the phases of recovery and rehabilitation. The nursing student is responsible for acquiring knowledge, mastering the programme content and obtaining and maintaining competence from the onset of the programme (Armstrong et al 2011:36). The teaching and training of adults encourages proactive approach to learning in which inquiry, autonomy and critical thinking feature predominantly (Hughes & Quinn 2013:22). According to Popil (2011:204) the utilisation of critical thinking skills are necessary in application of knowledge to the practice of the nursing profession to provide safe and 96  Analysis, presentation and description of the research findings 2016 comprehensive care. The development of critical thinking skills to acquire new knowledge and ways of thinking is regarded as a difficult encounter if the facilitator does not initiate mechanisms for collective support ( Machin & Pearson 2014:5).  Sub-category: Teaching and Learning strategies The participants reported the utilisation of varied teaching and learning strategies in the programme, and in some instances was dependant on the choice of the student during self-study. Most of the participants reported satisfaction with the discussion method as the student has to come prepared for the session more especially that there were other parts in the study guides that were assumed to be in place, meaning that the content was done during the basic programmes in professional nurse training and therefore became the responsibility of the students to work on their own so that they improve understanding of the content on the current study. The participants found the discussion and use of scenarios demanding and required students to reflect actively on their previous and current knowledge and experience in the meaning making process on the theoretical content. The participants assert that the learning strategies that were included were problem-based, small group discussions and structured group activities which stimulated critical thinking. The utilisation of interprofessional education was mentioned as a critical factor. Interprofessional education like radiologists, neurosurgeons, cardiologists and intensivists with relevancy was done during theoretical sessions in the classrooms through invitation of expert specialists to the module content and also in the clinical area during patient presentations, rounds, interpretation of blood results, and X-ray interpretations. The participants agreed that the critical discussion and exchange of ideas about the content in the programme increased the efficacy of learning in situations where the facilitator was actively involved and up to date with information. In contrast, the other participants revealed in their responses that discussion method and programmed learning sometimes left them in the dark when the educator was not actively involved. The students were expected to achieve 80% of their activities in theory based on the rules and regulations of the college. 97  Analysis, presentation and description of the research findings 2016 The following supportive quotations were pointed out: “...we [the participants] were given work to discuss and present although we didn’t have enough time to look at the other topics that were not allocated to us [the participants],we only focused on the topic allocated to you [the participants] and forget about other people’s topics, and you find that when they[other groups] are presenting you are left behind...” “...when you[the participants] are given a topic and you are divided into groups ... you are expected to present ...... you are expected to stand in front of this large number of people, if there is no confidence and you are anxious and tense...” “...I [the participant] think like in the introduction of theory after exposure what is happening normally a topic is given and the students are divided into groups and you [the participants] are expected to present...” “...I think in discussion after presentation the nurse educators must emphasise what is important on that topic. The students present one student after another without having any comment from the lecturer or without telling us [the students] what is expected from this module)...” “...I [the participant] think discussion is good because it encourage the students to be confident, and it helps the students to develop self-confidence...” “...the group discussion that we [the participants] promoted the group cohesion...” “...when we [the participants] were doing arterial blood gases, you will find that for the whole three weeks different groups kept on coming with different interpretations during discussions... until consensus is reached...” Discussion: Learning is a change in human disposition or capability that persists over a period of time and is conditioned by environmental factors that interact with the individual and includes the student, the stimulus, the contents of the student memory and the response or performance outcome (Hughes & Quinn 2013:79). Learning is a process which guides students to change in behaviour through activities and experiences or it may refer to the achievement of new abilities or responses which are additional to natural development, growth and maturation (van Vuuren, Kruger, Guse, 98  Analysis, presentation and description of the research findings 2016 Harper, & Netshikweta. 2012: 139). According to Brooks (2010:21) learning circumstances that challenge the students existing learning strategies require time and space where they can be able to voice out their frustrations openly with honesty so that they are given recognition to improve learning. Learning assumed to be in place refers to the information already known by the students before they are introduced to new knowledge, moving from simple to complex information. This implies that the student possesses prior knowledge that can be used to prepare the student for new knowledge (Chinn & Kramer 2008:9). The Higher Education Council in the criteria for programme accreditation (2012:11) under Criterion five (5) emphasizes that institutions should give recognition to the importance of the promotion of student learning through the utilisation of appropriate teaching and learning strategies relevant to institutional type and to make provision for staff to upgrade their teaching methods. Teaching and learning has two approaches namely, the teacher-centered approach and the learner-centred approach. The teacher-centered approach is where the teacher yields direct and overall control regarding presentation and teaching of the content to the student whilst learner-centred approach is direct involvement of the student with the learning content while the teacher becomes the lesser medium through which learning takes place (Bruce, Klopper, & Mellish 2011: 194). Furthermore Brooks (2011:44) is of the opinion that students’ struggle and challenges on encountering new knowledge or ways of learning is helpful in stimulating growth and transformation from being despondent. Pritchard and Gidman (2012:121) argue that in some actions that create anxiety in nursing students like, for example, during knowledge assessment in classrooms, have also been conducive to quick thinking, problem solving and high levels of mental performance. The South African Nursing Education and training standards (2005:17) emphasise the point that Nursing Education Institutions must prepare graduates who demonstrate critical, analytical and reflective thinking in the practice of health care. Mutually identifying a learning approach with individual students is the best method for facilitating reflective, autonomous practitioners to bridge the gap between theoretical and practical knowledge (Pritchard & Gidman, 2012:121). The Nursing Education 99  Analysis, presentation and description of the research findings 2016 Standards (2005:33) policy document emphasizes the utilisation of recognized approaches to teaching and learning by the nursing education institutions in their programmes. The approaches include, but not limited to, self-directed learning and e- learning to enable learner development. Experiential learning is increasingly used and accepted as being fundamental to professional development and work based learning for adult learning where previous experiences of the adult student can be utilised effectively (Mellish et al 2008:98; Erasmus et al 2013:226). The authors state that the elements of value for effectiveness in experiential learning include experience, reflections, actions and revisiting the experience. Programmed learning is also one of the strategies where the students are guided by the study guides on individual learning (Mellish et at 2008:134) although the disadvantage of the strategy is that the absence of lecturer-student interaction may lead to a lack of stimulation of the student. In the discussion type of strategy for learning, the students are divided into groups and a task for discussion is allocated and then presented through facilitation by the educator (Mellish, Brink & Paton 2008:117). Sharing of the work through group activities can decrease stress known to hinder learning. Group activities can promote understanding of the course content through face to face contact, friendship, positive interpersonal relations and cooperation with other students can help to ease the study process (Ward-Smith, Peterson & Schmer 2010:81). The utilisation of group activities in nursing students is encouraged as nursing activities are always achieved through team-work (Kinyon, Keith & Pistol 2009:165). Mellenium students need collaborative teaching and learning strategies as well as the use of technology for enhancement of team and individual learning (Trueman 2011:185).  Sub-category: Feedback The participants indicated concerns about failure by lecturers to give immediate feedback after every formative assessment. The participants expressed fear in making follow up on their formative assessment results. Sometimes the lecturers in other subjects give feedback towards the end of the programme when the entry marks into the examination are prepared; students are then told of their performance and the 100  Analysis, presentation and description of the research findings 2016 opportunity for a remedial test to qualify to write the examination. The failure to give feedback was supported by responses such as: “... it will be better after getting the results for the test if maybe they call us so that they give feedback and we can explain the problems that we are experiencing...” “...At least if we are called after each and every test so that we can have time to re-do the work not towards the end of the programme...” “... some of us were called at the end of the year and there was no more time to look at pitfalls. At least if we are called after each and every test so that we can have time to re-do the work...” “...Some of the students have that fear of consulting with the lectures even if they are struggling...” Discussion: Feedback is one of the fundamental activities in teaching and requires nurse educators to make it positive, clear and constructive with a focus on acknowledging the students’ successes and should guide them towards future improvements (Ferguson 2011:60). Feedback is a key factor affecting learning in educational setting and is used in the context of assessment where its main function is to provide information about students current performance, as well as constructive comments that enhances future learning (Parboteear & Anwar 2009:753) According to Ferguson (2011:57) the role and effect of feedback in students progress builds confidence and encouragement, as evidence shows that effective feedback is pivotal to improved student learning (Bruno & Santos 2010:112). The success of feedback depends on the educators’ knowledge of the difficulties, skills and personality of each student regarding a particular situation (Bruno & Santos 2010:119). Real learning takes place when feedback is used in ways that close the gap between where students are and the expectation of performance that need to be changed to close the gap (Ellery 2008:422). It is emphasised by Bruno and Santos (2010:118) that even if all the obstacles can be dealt with from the students’ path, there are always other factors such as motivational aspects, the students’ knowledge about the subject and practice skill that influence the performance of students. 101  Analysis, presentation and description of the research findings 2016 Feedback should be seen as an integral part of learning and a supported sequential process that involves provision of comments and suggestions to enable students to make their own revisions to gain new understanding rather than a series of unrelated events (Acher 2010:101). Students cannot convert feedback statements into actions for improvement without sufficient hard work to improve knowledge of some fundamental concepts (Sadler 2010: 537). The students emotion flexibility as an aspect of self-regulation is an important area of focus by educators as feedback that is not sufficiently explained and well-structured does not contribute in improving future practice and students learning (Scott, Evans, Hudges, Burke, Watson, Walter & Hudley 2011:64). Educators should pay attention to the structuring and processing of feedback to make explanation possible for students to understand propositional form of their construction to shift them from the present to the potential improvement (Shalem & Slonimsky 2010:771).  Sub-category: Nurse educators attitude towards students The participants argued that sometimes the Nurse Educator would argue with a student for a particular view point where the student was taught by another Nurse educator and in some instances it was found that the student was right. The attitude of some of the Nurse educators towards the students is perceived undesirable. Occasional late coming by the Nurse Educators was also experienced and sometimes delayed the process for the day. “...Remember lectures are also human beings with emotions, some don’t take arguments with students over content lightly they end up distressing and when they are distressed they transmit it so it will have a negative impact on you [the students]...” “It is very easy to argue something that you[the student] have seen, but the challenge is the Nurse educator telling you that she is the senior she knows better so you won’t have a basis to stand...” “...To us [the participants] it shows that they [the nurse educators] don’t 102  Analysis, presentation and description of the research findings 2016 communicate if they communicate they were not differ with the information they are to give to us ... they can share the information before they come to us...” “...To add on that even when you [the participant] are given a script and you are told not to come back. That is painful and it shows that they [the nurse educators] marked you wrong on something which is right. I don’t want to see other student going through what I experienced...” “...sometimes you find that the student is having that fear of consulting with the lectures...” Discussion: Armstrong et al. (2011:36) aver that respecting the students’ right is the responsibility of the nurse educator and the Nursing Education Institution. This requires fair processes and a quality education that empowers the students with clinical competence based on sound theoretical knowledge that will ensure that all clinical activities are done on time and clearly understood to produce a reflective, critical thinking student who will respond effectively to situations in the clinical practice that requires emergency care. Reflection is seen as part of the art of nursing, which requires a nurse to be resourceful, utilising conscious self to critically analyse and evaluate the clinical situation in order to apply knowledge for effective decisions and actions to improve the quality of care (Finkelman & Kenner 2013:59). Environments characterised by mutual respect and positive regard reduce student anxiety, thereby enhancing cognitive function (James & Chapman 2009:36). Given the benefits to student learning, it is not surprising that students identify relationships as critical to their satisfaction with the placement experience. Relationships are important to students because of the support and sense of belonging they provide (Gallagher, Carr, Wang & Fudakowski 2012:335). Regardless of health discipline or country, students consistently report they need to feel respected, appreciated and part of a team (Brown, Williams, McKenna, Parlemo, McCall, Roller, Hewitt, Molloy, Baird & Aldabah 2011:25; Rodger, Fitzgerald, Davila, Millar, Allison 2011:195). The study by Anderson and Seymour (2011:87) revealed that ineffective communication by nurse educators led to poor relationships. The participants’ in this study reported condescending and insensitive manners, negative and humiliating comments, and failure by lecturers to listen as having an adverse impact on learning and wellbeing. 103  Analysis, presentation and description of the research findings 2016 An environment of care, respect and collaboration is believed to be an outcome of the educators’ attitude, trust and building of relationships with students and can help in facilitating change (Brooks 2011:44). It is suggested that the nurse educator should display qualities such as a non-judgemental attitude, generosity, confidence, honesty, willingness to take risks, be motivated to educate students and be in the lead without showing off (Meyer & van Niekerk 2008:107). Imagine yourself as the facilitator in the programme: which aspects in theory will you change to refine the programme? 4.3.2.1.6 Category: Continuous professional development for Nurse Educators The competency of some of the nurse educators was doubted by some of the participants who speculate that some nurse educators lack knowledge on certain content and tend to argue with students when trying to emphasize some points on the related content. Based on this attitude the students mentioned the development of anxiety and fear of consulting the Nurse Educators in instances where the content at hand is not well understood. The participants mentioned that there are five nurse educators for the four post basic programmes run by the institution that were involved in teaching Internal Medicine and Surgery (IMS) and sometimes they differ on explanation of the same content. The participants who mentioned that they trained during the initial inception of the programme claim that that there was a time when one Nurse Educator was teaching nursing dynamics and internal medicine and surgery in four post basic programmes that are run by the institution. “...Presenting without having any comment from the lecturer...” “...sometimes they (Nurse educators) will differ with content that they were referring to at …it was just confusing because one come and teach us the other one comes and teach us ….sometimes you spend the whole 30minutes arguing because the lecturer is not agreeing with you [the participant]...” “...but sometimes it becomes a challenge like with the interpretation of arterial blood gases , ... nurse educator A would come and say I[the nurse educator] know this 104  Analysis, presentation and description of the research findings 2016 better what your nurse educator told you[the participant] is out of line this is how we are doing it and it becomes a confusion...” “...It is true, there is lack of communication because in emergency nursing the nurse educator will be teaching respiratory system and in IMS the other one will be teaching you the same system but when tests are written and then you write as guided by the emergency nurse educator you get zero...” Discussion: According to Muller (2011:353), professional development can be defined as the individual’s or student’s own personal development responsibilities that must be in accordance with regulatory requirements. Echoing the same sentiment, Gravett and Geyser (2007:38) claim that the behaviour displayed by educators can almost certainly restrain or improve the learning of students on a sub-conscious level. In the same vein, Parboteeah (2010:2) avers that educators should think of themselves as active socializing agents skilled to inspire students to study. The nurse educator as an expert practitioner should demonstrate the ability to think critically and continually utilize interactive debate to stimulate critical thinking in the student (Muller 2011:347). Armstrong et al. (2011:36) admits that knowledgeable nurse educator actions create a critical thinking practitioner who is able to take individual decisions in the care of the critically ill patients. Hallstead and Frank (2011:30) are of the opinion that facilitating the learning of students requires that the educator be knowledgeable with regard to relevant theory for utilisation in designing the students’ learning experiences, and developing skills for the utilisation of a variety of teaching strategies. The authors further hold that nurse educators need to develop and maintain expertise in nursing practice and education. According to the Council of Higher Education (2012:18) the staff responsible for academic development must be adequately qualified and experienced for their task and their knowledge must be regularly updated. Continuous professional development and self-evaluation should be an ongoing process in nursing education in order to identify individual shortcomings, broaden their knowledge expertise and competence to improve personal and professional qualities. (Muller 2011:8; Chang &Daly 2015:323). 105  Analysis, presentation and description of the research findings 2016 How do you prefer the theory to be improved? 4.3.2.1.7 Category: Rules and regulations regarding training The participants argue on the intractable process of how the approval of study leave is granted by the Provincial Health Department, especially the unavailability of pre- registration learning package from the nursing education institution, the practice of research within the program and the academic training period as stated by the South African Nursing Council (SANC). The participants expressed concern on late approval of study leaves by the Provincial Health Department. Late study leave approval was seen as a delay in the students’ psychological and physiological preparation and it also demotivates other students who are informed after their institutions have already sent them for exposure at accredited institutions for training, which is a pre-requisite to meet the criteria for admission to the programme. The participants indicated that according to the prerequisite criteria for entrance into the programme, the prospective candidates for the programme should be placed for the period of 12 months in the emergency unit of the area of employment for exposure and 4 months at the accredited institution for training within the Limpopo province. Some of the participants speculate that they only began to understand the expectations for pre-exposure towards the end of the fourth month at accredited institutions for training. The participants believe that the amount of the work in the curriculum was too much for the given academic period. The participants in both focus groups associated their academic failures to the length of academic training period and allege that the training period be lengthened to at least 18 months to accommodate also weak students in understanding the amount of theoretical content within the programme. Research proposal and report presentation are some of the requirements for nursing dynamics completion in the post basic nursing programmes. The practice of research in the institution is chaotic in such a way that the students are invited to come back for the research reports after completion of training. The delay is said to be brought about by the process to be followed as required by the provincial department. The participants felt that the orientation was not enough without the pre-registration learning package with some 106  Analysis, presentation and description of the research findings 2016 form of assessment to orientate the students to the theoretical content. The participants are of the opinion that a pre-registration learning package will introduce students into the programme and can also be utilised as selection criterion to determine the suitability of candidates for the programme. According to the participants the pre-package should provide information on the expected knowledge that is assumed to be in place to provide better understanding on the learning content for the programme, and students should be assessed on the given package. “...maybe if they [the Department of Health] can approve the study leave maybe before we[the participants] go for exposure and then given the objectives of what is expected from the students during exposure...” “...So before the students are released for exposure the study leave need to be approved and the nurse educator will know that there are for example 20 students for emergency nursing programme to make planning easier...” “... I [the participant] think the exposure period can be at least it can be 16 months when adding four months to the 12 months that is currently prescribed...” “...by the time you start to realise or understand the expectations during the programme, it is already the end of the year and you are to write the examination, so the period is not enough...” “...During the training period towards the exam time some of us [the participants] were writing optional tests because we did not qualify to write exam so that was happening in a short period of time to support 12 months not being enough for the duration of the course...” “... I [the participant] think the theoretical content was too much for the given period of training...” “...The theory part of it is too much ...immediately when we [the participants]come for exposure we are not just exposed to the practical part of it, that we are also introduced to the theory...” “...The expected work [content] is too much we don’t even finish in time...” “...To be honest the scope is too much, a year is not enough I [the participant] don’t know how will it be but an extension of six months won’t do any harm...” “…we [the participants] also have to come back after completion of the programme for presentation of the research report...” 107  Analysis, presentation and description of the research findings 2016 “…like after you [the participant] have written the examination you have to come back for research presentation and as we [the participants] know that it takes time to get approval through the channels that it has to go...” “...during the introduction period, it is advisable that an introduction package is utilised to evaluate the students during exposure…” “…I [the participant] think before anyone can come to the course a pre-registration learning package is given so that the students can work onto can answer all the relevant questions. It will sort of give you [the participant] a guide of what is expected in theory. It must be part of the selection criteria…” Discussion: The Limpopo Provincial Health Department study leave guidelines for nursing personnel (14) states that the approval of study leaves is the jurisdiction that solely rests with the Head of Department. It is the responsibility of the Nursing education institution that decides on the criteria for admission of students into the post basic programmes. Nurse Training is governed by the Nursing Act, Act 33 of 2005 as outlined by the South African Nursing Council (SANC). Statutory regulations provide structure and boundaries that can be understood and interpreted by both professionals and the public (Fraser, Nolte & Cooper 2009: 81). The SANC reviews training programmes continuously to meet the educational requirements of students. The SANC also issue guidelines to training institutions according to the accredited programmes. The academic training period for the emergency nursing programme is 12 months, according to Regulation R212 as amended by Regulation 74 of 1997 from the SANC. A research proposal has to be ethically acceptable to be approved by the ethical committee for protection of the rights of the individual participants and adoption of research findings in nursing practice (Brink, van der Walt & van Rensburg 2012:45). Research utilisation is essential in developing evidence based practice in the delivery of quality, cost effective health care (Grove, Burns & Gray 2013:468).The findings in the study by (Jelsness-Jorgensen 2014: e4) indicated that students perceived research as of no importance to use in the future of health care delivery as evidenced by a minority of students who read scientific papers. Evidence-based practice is a philosophy of clinical activity that is founded on sound research evidence. The 108  Analysis, presentation and description of the research findings 2016 associated practice also takes account of professional consensus of opinion and client acceptance to comply with ethical considerations of research (Hughes & Quinn 2013:530).The participants who value research practice in Millberg et (2013:719) indicated that meaningful academic learning constitutes an important knowledge for lifelong learning now that they can read and evaluate research articles and therefore give inputs formulated on research-based knowledge. An Australian study undertaken by Martin and Considine (2005:40) found that by introducing an education programme prior to the implementation of an emergency nurse practitioner (ENP) programme, the staff reported significantly increased understanding of the requirements and functions of an ENP. Bruce et al (2011:305) concede that assessment is a means of obtaining data about the students’ performance towards the achievement of the expected outcome of the programme. The definition of selection for this purpose will be the mechanism utilised for resolving who will be accepted for training as a student nurse at a health care institution (Bennet & Wakeford 2012:6). It is the ethical obligation of institutions of learning and educators alike to ascertain that the criteria they employ to recruit and admit students is of such a nature that it attracts the candidates who are efficiently equipped with knowledge and skills that are necessary for emergency nursing (Ali 2008:129). The author further states that in order to ensure sustained competitiveness and accountability it is crucial that nursing programmes should have effective, efficient and reliable admission criteria that ensure that selected students have the knowledge and skills needed for their chosen discipline. 4.3.2.2 Theme 2: Delivering the practice in the clinical setting Clinical exposure was another important component that was identified by the participants for effective training in emergency nursing practice. The subthemes and categories are summarised from table 4.3.3.1. to 4.3.3.5. 109  Analysis, presentation and description of the research findings 2016 Share the most exciting peak experience that you had as a student in the clinical area during your training for the emergency programme? The responses indicated that the participants had positive experiences in the clinical area with regard to pre-registration exposure, relationship with clinical staff, competencies acquired during placement and interprofessional team work amongst health care professionals. 4.3.2.2.2 Category: Positive clinical experiences The participants indicated appreciation, satisfaction and improvement in the practice of emergency care. Gaining clinical experience was stated by the participants as one of the main factors that enabled students to survive working in emergency and intensive care departments. The participants also explained that these positive experiences made it easier for students to deal with patients, staff and the multidisciplinary team members both physically and psychologically. The clinical experiences enhanced the students’ feelings of confidence in dealing with patients requiring emergency care. These positive emotions included feelings of reward and satisfaction as well as making a difference in their practice. Pre-registration clinical exposure is viewed by the participants as an important aspect to orientation of the students to various clinical situations that requires emergency clinical skills. The pre- registration exposure is regarded as a foundation for knowledge and practical skills for advanced practice. These exciting experiences of positive changes in practice and attitude in the emergency programme were confirmed by the following responses: “...I [the participant] can say the course is of high standard you can work competently in any of the units were critically ill patients are cared for...” “...we [the participants] went to casualty one day to check if we can find procedures, the patient who had gun-shot wound to the chest was found ... we checked the X- Rays of the patient ... diagnosed that the patient had lung injury and liver rupture so when the doctor was asked about the diagnosis and he did not agree with us [the participants] , ...by then the bullet was on the right side of the abdomen, ... So when 110  Analysis, presentation and description of the research findings 2016 the patient came back from the CT (Computed Tomography) scan ..,we were told that we were right ... the patient has got a lung collapse and a ruptured liver, so that was one of the things that…(laughter)...” “...we[the participants] were proud because we managed to diagnose things that the doctor could not see...” “...we [the participants] urge the student to come for exposure before they can be taken into the programme] so that things can be easier for them because other professional nurses are from peripheral hospitals where there are no equipment ...“ “...I [the participant] have a feeling that the exposure period forms the most basic aspect for succeeding in the course [the programme] but I will agree that in the very exposure period there should be a programme that assists those people who are coming for exposure...” “...When I [the participant] look back on the course [the programme] itself I think it is very important that a person understands of human anatomy and physiology... like cardiovascular, respiratory, neurovascular and renal systems…those systems that are very critical in understanding the conditions and the treatment of the critically ill patients...” Discussion: Wigens and Heathershaw (2013:226) state that clinical practice settings are considered to be the most influential aspects of nurse education programmes where students interact with the clinical staff, patients and families for the purpose of acquiring critical thinking, clinical decision-making, psychomotor and affective skills to archive their respective placement outcomes. To reinforce this further, Baglin and Rugg (2010:145) point out that clinical exposure can improve the students’ enthusiasm and maturity towards professional identity. Clinical experience is believed to be “undisputed as a key to professional competence” (Courtney-Pratt, FitzGerald, Ford, Marsden, & Marlow 2011:1381). Effective clinical placement can improve nurses’ competency as such, during clinical placement the students reach a level of confidence to handle different situations and realise expectations and objectives for the particular area (Manninen, Scheja, 111  Analysis, presentation and description of the research findings 2016 Henriksson & Silen 2013:193). The authors further posit that clinical exposure improves the students’ independence and the ability to link the previous experiences, knowledge and skills into the new whole. Positive emotions were clearly identified in the study by Alzghoul (2013:20) in the experiences of nurses working with trauma patients in critical care unit and were expressed as making a difference through the utilisation of life saving measures by moving the patient’s progress from being sick to being normal again. The findings further revealed that working with trauma patients requires an advanced level of appropriate knowledge and skills in order to meet the demands of care needed by these patients. Which aspects do you value in the clinical practice of the programme?  Sub-category: Relationship with clinical staff The participants agreed that they had good relationships with clinical staff. Good relationships created better opportunities for learning, support and clinical practice improvement and that was found to facilitate learning. The clinical staff initiated learning opportunities for learning during morning lectures where patients that were seen the previous day were presented and given management was evaluated for appropriateness and relevancy for the presenting symptoms. The participants viewed the practices as valuable for clinical knowledge gain that was utilised at the respective institutions where there is always shortage of medical doctors to save lives of patients presenting with emergency conditions. “...there are many specialist in trauma [emergency] nursing who want to teach us [the participants] , is like there is no time isn’t it learning is continuous...” “...there is good support from the clinical personnel...” “...I [the participant] want to appreciate on the early morning lectures between seven and eight, I found that to be very motivating to keep on preparing... some of the things you[the participant] will just write without even going to the books you will just remember what they [the clinical staff] told you...” “...When the night staff and the day staff are giving report especially in the resuscitation room is a learning curve. You start with patient A, B, C with the trauma 112  Analysis, presentation and description of the research findings 2016 slogan...” “...on the principles of mechanical ventilation….when doing the setting of a ventilator I [the participant] found it very good that even to interpret some of the things...” “...(nna) I [the participant] would say maybe I was lucky I was exposed to theatre in Mankweng hospital, we [the participants] were lucky in that each and every day we were given chance not just time but sufficient time to learn and practice...” “...The nurse educators demonstrate procedures [skills] to us and then the skills are practiced with the supervision of the clinical staff before the nurse educators can evaluate us on what they showed us...” “...isn’t it that we [the participants] come here to learn this, some of us are working in rural hospitals where there are shortage of doctors for example doctors in the emergency unit as a trauma [emergency] trained nurse one is expected to relieve any emergency case you come across, like we learn how to intubate patient to open and maintain the airway...” “...the relationship between the students and the people working in the clinical area, they [the clinical staff] are very supportive, always ready to help the student...” Discussion: Bisholt, Ohlson, Engstrom, Johansson and Gustafsson (2014:303) concur with the World Health Organisation (2010:476) which emphasizes that learning to listen to, understand and respect the perspectives of others in the interprofessional (multidisciplinary) team is essential for successful learning, collaborative working and the improvement of health care practice. Searle, Human and Mogotlane (2011:182) state that a variety of nursing activities and duties cover a large area of responsibilities and it is increasing steadily with the implementation of specialised programmes like emergency nursing. All areas of health care that deal with the human mind and body are the nurse’s concern. Health care is a co-operative activity that is provided by persons registered under different bodies for specific professions like South African Nursing Council through the Nursing Act, medical, dental and supplementary health professions acts. Nurses have to work hand in hand in clinical practice with other members of the health care 113  Analysis, presentation and description of the research findings 2016 profession and establish a multidisciplinary rapport in order to ensure growth in medical science, as well as development and implementation of care concurrent with nursing science (Searle, Human & Mogotlane 2011:114). The students in a study by Boughton, Halliday and Brown (2010:358) were of the opinion that training under the masters programme provided them with a source of support by fostering a sense of belonging, providing an identity and facilitating the development of cherished friendships which in turn made the students feel valued and important.  Sub-category: Competency in clinical practice The findings in this study indicate the participants perceived their own capacity to treat the presenting emergency conditions as the strongest factor in determining their scope of practice. This indicates that the participants felt that they had control over their role by virtue of the acquired knowledge and skills in the emergency practice. The clinical activities undertaken by the emergency nurses in this study demonstrate achievement of clinical competencies. “...Since we [the participants] came into this course we understand emergency management more and even to do certain procedures like an intubation interpretation of ...and ECG...” Discussion: The American Nurses Association (ANA) standards (2010a: 64) define competency as “an expected and measurable level of nursing performance that integrates knowledge, skills, abilities, and judgment based on established scientific knowledge and expectations for nursing practice”. Competency is the sum total of effective clinical behaviour that a student is expected to demonstrate in clinical practice. Competence means the ability of a practitioner to integrate the professional attributes including, but are not limited to knowledge, skill, judgement, values and beliefs required to perform as a professional nurse in all situations and practice settings (Nursing Act 2005:21;Finkelman & Kenner 2013:130).The ANA standards define competency as “an expected and measurable level of nursing performance that 114  Analysis, presentation and description of the research findings 2016 integrates knowledge, skills, abilities, and judgment based on established scientific knowledge and expectations for nursing practice” (2010a: 64). Literature concerning knowledge for emergency nursing practice focuses on the acquisition of clinical skills as the most significant aspect for the role (Duffield, Conlon, Kelly, Catling-Paull & Stasa 2010:181).  Sub-category: Interprofessional teamwork The participants reported positive relationships with other health care teams in the management of the critically ill and injured patients in all environments of clinical placement. “...the medical doctors and other health care personnel must be informed about the trauma [emergency] students so that learning is continued...” “...I remember at one point we were struggling to find patients for intubation at Mankweng Hospital as there are interns (medical doctors doing internship) ... because the communication was not very clear between the nurse educators and the doctors ... the chief medical officer will not allow you and he [the chief medical officer] also needed to teach medical interns who were always given first preference ...” “...I [the participant] think because they (medical doctors) know that Mankweng and Pietersburg Hospitals are training institutions they need to be told that students that are placed there also need to do clinical trauma [emergency] training...” Discussion: Interprofessional teamwork is sometimes referred to as multidisciplinary teamwork, for all health care professionals practicing with the aim of improving the patients’ health. Finkelman and Keller (2013:302) describe interprofessional teamwork as improving cooperation, collaboration, communication and integration of health care activities in these teams to ensure that there is continuous and reliable care. Interdependence and collaboration among health disciplines is essential to achieving positive patient outcomes (McQuillan, Makic & Whalen 2009:91; Urden, Stacy & Lough 2014:10). 115  Analysis, presentation and description of the research findings 2016 Finkelman and Keller (2013:311) agree that interprofessional teams promote education but requires the following competencies by professional health team members:  Application of relevant values to build effective relationships amongst health care teams for quality patient care.  Creation and maintenance of a climate of mutual respect and shared values.  Utilisation of the nurse practitioners knowledge and role with those of other health care professionals to appropriately meet the patients’ health care needs.  The utilisation of communication to inform other professionals on the care of the patients for appropriate responses on patients and families with regard to maintenance of health care and treatment. Learning to listen understand and respect the perspectives of others in the interprofessional team is essential for successful collaborative working and the improvement of health care (World Health Organisation 2010:476). The students in a study by Boughton, Halliday and Brown (2010:357) reported a sense of friendly competition amongst the group members, a phenomenon which motivated them to move forward with their studies. Tell me about the challenges experienced in the clinical area during training? 4.3.2.2.3 Category: Negative clinical experiences The students were exposed for the period of four months to the specified units during exposure period before enrolment into the programme for orientation. Students reported being placed at different clinical areas to acquire clinical skills as specified in the clinical workbooks. Placement is done in the following areas: Emergency care unit, Intensive care units (general, cardiac and pediatric) burns unit, operating theatre and renal unit. It was reported that sometimes in critical care units there was lack of support, as the students were given patients to nurse on their own, used as workforce based on shortage of personnel. 116  Analysis, presentation and description of the research findings 2016 “...based on our [the participants’] experience exposure period is like being on our own, we [the participants] don’t have anybody to mentor us...” Discussion: It was acknowledged in a study conducted by Ohaja (2010:14.6) that factors which contributed to negative experiences and sudden enormous responsibility on the students included shortage of staff, resultant increased workload and lack of time for clinical personnel to support the students so student felt abandoned. The registered nurses in the clinical placement areas feel that having been overburdened with work, inadequate support by the education faculty and health provider, as well as not having been sufficiently trained and prepared for supervising student nurses impacts negatively on their interaction and relationship with students (Bruce et al 2011:255). The overburden of work by clinical staff results in increased exposure to tension between workplace and student priorities (Hegenbarth, Rawe, Murray, Arnaert & Chambers-Evans (2015:307). To alleviate this, Meyer et al. (2010: 9) stipulate that clinical practice should be reflective of theory and that it should be guided by its purpose, point of departure, leading principles and the obvious, conspicuous interrelatedness of all these factors.  Sub-category: Inadequate pre-exposure period There are varied factors envisioned by the participants’ responses for contribution to the success and future of the programme. The pre-exposure period for four months at accredited institutions for training of post basic programmes in the Limpopo province, is regarded as entry requirement into the programme. The participants mentioned pre- exposure period of four months as inadequate and of no value if not utilised effectively. The participants reckon the pre-exposure period is an important time for orientation of students to the programme if not only utilised for clinical practice, but important for also theoretical aspects of learning. The participants are for the idea that the period should be formal and well-structured to motivate the students. The ideas were supported by the following responses. 117  Analysis, presentation and description of the research findings 2016 “...They [the Nursing Education Institution] introduced exposure period to aquint the students with the activities in the programme, I think maybe if we were using it to our best benefit not for practica only but also for theory...” “...I [the participant] just want to say without fear or favour the four months of exposure is wasting time if not utilised effectively, if it can be structured in such a way that it will trigger inquisitiveness in students, you[the students] can cover a lot in that four months...” “...we are coming from far [rural] areas where things like Electrocardiogram (ECG) monitors are not available , if the four months is well structured then the students will come prepared when coming for actual registration into the course [programme]...” Discussion: This is consistent with the systematic review of Happell and Gaskin (2012:149) who believe that limited time exposure in mental health, also a specialization, results in nursing students not considering mental health as a specialization. Adequate exposure period is regarded as valuable for students to have an idea of the complete expectations within the programme.  Sub-category: Shortage of clinical personnel The participants in this study emphasised shortage of personnel at the clinical environment which result in missed learning opportunities, lack of support at the clinical environment by the clinical staff. Failure by nurse educators to do clinical accompaniment was also noticed. It was also indicated that the Department of Health in the province seem not involved in solving the problem. This was supported by the following responses: “…in Intensive Care Unit we [the participants] are allocated to patients and whenever clarity is required the first supervisor will say go to the next supervisor or go to the shift leader and the shift leader will be saying I [the shift leader] am having this and that to do… and I am alone maybe we are four as students and the staff are maybe six, they [the staff] will say no I am having too much she can’t even look at me…” 118  Analysis, presentation and description of the research findings 2016 Discussion: Nursing shortage is considered a global major barrier that affects the nurses’ productivity, competency and their commitment to the health care organisation that they work for (Jooste & Jasper 2012:59; Mokoka, Oosthuizen & Ehlers 2010: 9). South Africa, as supported by literature from other countries, is also experiencing a serious shortage of nurses which has to be addressed to prevent the crises in health care services (Mokoka, Oosthuizen & Ehlers 2010:9). The decreasing output of nurses from the nursing education institutions is regarded as a debatable issue based on the increasing shortage of nurses (Searle, Human & Mogotlane 2011:349). A heavy workload, due to personnel shortages and insufficient time for completing nursing tasks, results in reluctance of professional nurses to supervise students (Armstrong et al 2011:88).The author emphasise that without sufficient nurse educators in the system, educational programmes cannot be offered at the required level of quality.  Sub-category: Students as workforce In the findings for this study, the participants reported that shortage of staff was a major challenge that impacted negatively on student nurses during clinical placements. It emerged from the participants that during the clinical exposure period before participants were registered into the programme, the learning objectives were not met so the prospective students ended up doing routine work in the unit without considering the main reasons why they were placed there due to shortage of staff. Shortage of staff led to trained nurses’ inability to supervise participants. “...now with the exposure period is like they [the students] come and just work like any other person...” ”... every student who goes for exposure becomes a workforce there is no way that we [the students] are focusing on academic matters ,that is; what we [the participants] are going to be doing during the course [ programme]...” “...Most of the time the students are just send to Pietersburg and Mankweng hospital for exposure and workbooks are given ...there is no supervision we [the students] are just working...” “...The purpose of exposure is preparation, but now is not serving that purpose 119  Analysis, presentation and description of the research findings 2016 people ...too much focus is put on relieving clinical staff members...” “...The primary purpose or the primary requirement is that I (the student ) should complete four months of exposure period...” Discussion: According to a study by Chuan and Barnett (2012:194) on perceptions on the clinical leaning environment students reported a variety of learning opportunities which facilitated learning, however in most instances these opportunities were compromised by increased workload with routine tasks and sometimes non- nursing duties. The aspect of balancing the appreciation of being included and valued as a staff member and being (mis)used as merely a pair of hands during their clinical studies was another concern mentioned by many of the participants. This balancing act, which can often be difficult, is also outlined in other studies by Bradbury-Jones & Sambrook (2011:370) and Magobe, Beukes, & Müller (2010:184). Contrary to the shortage of personnel, students appreciate being valued as a health care team members in the nursing units (James & Chapman 2009:40 ), but on the other side, they may feel uncomfortable when they are used solely as work force rather than being valued as students learners (Magobe et al 2010:185). Experiences of being ignored and misused as health care assistants or purely work force is shown to cause a great deal of emotional stress for students in clinical settings (Haugan, Aigeltinger & Sørlie 2012: 156). The feeling of being seen, heard and valued as individuals as well as students is described as an important prerequisite for experiencing good learning situations (Bradbury-Jones, Sambrook & Irvine 2011:370; Haddeland & Söderhamn 2013:26). The Strategic Plan for Nursing Education, Training and Practice (2012/13-2016/17:30) stipulates that in order to meet the needs of nursing education, a national nurse educator development framework is necessary to ensure adequate numbers of appropriately qualified nurse educators in both clinical and theoretical spheres of nursing. Considering clinical supervisor and student ratios global standards recommend student groups of not more than 15 and preferably nurse educator-student 120  Analysis, presentation and description of the research findings 2016 ratios of 1:15-20 for pre-registration clinical training and supervision (Strategic Plan for Nursing Education, Training and Practice, 2012/13-2016/17:74). Nurses and other health care professionals of the multidisciplinary team are compelled to improve their communication skills due to remarkable changes in the health care environment such as an increase in the number of highly acutely ill patients coupled with severe nursing shortages and complex communication technologies (Miller, Riley & Davis 2009:247).  Sub-category: Anxiety and frustration The participants experienced anxiety and frustrations as an outcome of poor support when it is needed in the clinical environment. The intensive care unit (ICU) is a twelve bedded unit and in most instances the permanent staff do not even reach 12 where the students ends up being allocated to patients alone without mentoring. Initial clinical experience especially in the Intensive Care Unit was the most anxiety producing part of the students’ clinical experience as they had fear of making mistakes and doing harm to the patients on manipulation of various monitoring equipment around the patient of which they had no skill to operate them. Some of the procedures and equipment in ICU were new to many of the students from rural institutions and they required support during execution of care to critically ill patients to avoid mistakes. “... whenever we [the students] go to ICU we are given a patient and you [the student] has never met the supervisor ---- they [the clinical staff] just say that is your patient, there is no other staff allocated with you on the patient, I [the student] will be alone with the ventilator with so many tubes...” “...after such experiences, out of fear to make mistakes I [the student] go to the doctor to get sick leave so that those days of exposure must pass...” “...if the shift leader is overloaded with work and the other patient is crushing [condition deteriorating] that side (eish)…. it makes us to be frustrated...” Discussion: Students may experience anxiety due to a number of factors (Warren 2010:1364). These factors might include the first clinical experience in performing a procedure, or that they are scared to make mistakes when executing clinical skills. 121  Analysis, presentation and description of the research findings 2016 This is consistent with studies done by Watkins, Roos and van der Walt (2011:4) in which they assert that students experience disillusionment when they are confronted by reality and that it increases stress levels. Nurse educators have the responsibility to ensure that students receive demonstrations in practice of all the nursing procedures that they are required to perform, to decrease nursing students’ fears of making mistakes in the clinical learning environment (Meyer & van Niekerk, 2008:108).The students express frustration at having little opportunity to work independently with confidence in this supervisory situation with minimal support (Bisholt, Ohlsson, Engstrom, Johansson & Gustafsson 2014:308). Hooks (2010:21) argues that in situations where students are anxious and frustrated there should be a balance between managing students’ frustration and challenging their beliefs. Students require space to be open, name their fears, speak out so that they can also celebrate the peak moments where everything clicks and collective learning is taking place. Anxiety and frustration can disrupt normal functioning in an individual, including the person’s relationships with others and the ability to make judgements and take decisions in practical performance resulting in inadequate coping skills (Hughes & Quinn 2013:365). This is consistent with studies done by Watkins et al. (2011:4) in which they assert that students experience disillusionment when they are confronted by reality and that it increases stress levels.  Sub-category: Theory and practice gap The participants experienced a gap between the theory that was learned in classroom and the reality in the practice of emergency care. Participants view the practice of clinical skills without support from experienced staff as compromising the patients’ safety. “...the students interact with clinical staff who only teaches what they can remember that is practically based without linking to theory...” “... isn’t it that when you [the student] are in the clinical area you can’t just start working without being guided, you have got theory, is just that you haven’t done the 122  Analysis, presentation and description of the research findings 2016 some of the procedures before, you have to correlate your theory with practical for safe practice...” “... the link of the theoretical part with practical is somehow bridged to an extend that we [the students] qualify without literally completing the expected number of scarce procedures required in the course content...” Discussion: The theory practice-gap is described as the disparity between what has been learned in the classroom setting and what is practiced in the clinical environment (Kaphagawani & Useh 2013:182). The existing gap between theory and practice can affect the competency of the students and which ultimately affect the patients safety (Michaur, Robert, William & Boyle 2009:23).Theory and practice are not interchangeable (Boyle, Williams, Cooper, Adams & Alford 2008:1). The transition from the theoretical setting to the clinical practice site is commonly a time of apprehension for the nursing student. The clinical learning environment is a complex social entity that influences student learning outcomes in the clinical setting (Papastavrou, Lambrinou ,Tsangari, Saarikoski, & Leion-Kilpi 2010:176). Evidence from literature by Safadi, Saleh, Nasser, Amre and Froelicher (2011:422) in Jordan students reported disparities between what was learned in class and the actual practice in clinical areas. Theory contributes to the understanding in performing a practice in a particular field, theory is fundamental to the practice implementation that is to be translated to the real situation and the two processes must be balanced, an imbalance create a theory practice gap (Scully 2011:96). There is a need to recognise clinical practice and theoretical learning environments as equally important, rather than dissociated entities that make the transition from student-learner to learner-worker more difficult (Newton, Billet, & Ockerby 2009:332; Koontz, Mallory, Burns & Chapman 2010:244 ; Gallagher, Carr, Wang & Fudakowski 2012:335). Students must be provided opportunities to transfer classroom learning to the context where this learning applies. Real learning in nursing practice comes from clinical environments, and is a necessary component of clinical education (Yardley, Teunissen & Dornan 2012:108). 123  Analysis, presentation and description of the research findings 2016  Sub-category: Clinical placement at the Emergency Medical Services (EMS) One of the areas for clinical placement of students was at the pre-hospital environment where students do not understand the reasons for being allocated in the area. The expected role played by each member from the pre-hospital team was not clearly understood. The participants argued that they are constantly allocated under the supervision of a junior personnel below the level of their practice and do not acquire any clinical skills. “...I the participant] still don’t understand why we [the students] go to Emergency Medical Services (EMS), we just run around with the paramedics and they don’t seem to understand why we are there...” “...at (EMS) and we [the students] work with people who are under qualified so they will never teach you anything. In turn we are the ones who teach them...” “...The objectives are the same, because there you are going to wait for the patient and transfer the patient to casualty [emergency ] unit for…so I think they are still the same it is just that there you are initially with the patient...” “...because we [the students] must see how they do the primary survey while out of the Hospital...” “...we [the students] did not benefit anything...” “...Most of the interesting cases at EMS happen during the night and we[the students] are not given an opportunity to work during the night at EMS so maybe according to my understanding that is why we [the students] are missing most of the cases. We report on duty at 07h00 and knock off at 16h30”. the interesting cases come after 16h00 and we miss a lot of things...” “...my [the participant] suggestion is that students should report at the EMS college If there are no paramedics at the stations so that the student are taken along by the paramedics on dispatch ...When there is no calls they[the paramedics] can still teach some of the things ...they are lecturers in actual fact...” “...if let’s say you are a paramedic, ...as long as they say students are coming you [the paramedic] must get ready to teach the students...” 124  Analysis, presentation and description of the research findings 2016 Discussion: ‘Pre-hospital’ describes the phase when Health care providers attend to the needs of patients outside the hospital. The training and recognition of emergency nurses and pre-hospital personnel help in evaluation of patients’ needs and choosing the best treatment options (McQuillan, Makic & Whalen 2009:92). At pre-hospital environment specific skills are required when handling patients with multiple trauma injuries to stabilise the patients’ vital signs and maintain vital functioning (Abelsson & Lindwall 2012:67).The emergency nursing programme is viewed by Boyd (2011:187) as a medical advancement for nurses to promptly deliver scientifically sound clinical practices in an environment that requires multidisciplinary cooperation, infrastructure modification and new component operational interactions. In a study by Gallagher et al (2012:336), students said that appropriate and organised placement had an influence on their experience of the clinical placement. McCall, Wray and Lord (2009:9) found paramedic students frustrated when supervising staff were unaware of their impending arrival, role, and learning requirements. Several studies have identified the need for clearer communication about what supervisors can expect of students (Henning, Shulruf, Hawken & Pinnock 2011:85 ) and what students can expect of supervisors in various clinical settings (Rodger Fitzgerald Davila, Millar & Allison 2011:98 ). It is considered important for the emergency nurse to assess the pre-hospital scene to find out what happened at the time of injury in order to analyse and interpret the impact of injury based on the mechanism of injury and the impact of the energy endured by the patient (Abelsson &Lindwall 2012:69). Which aspects in clinical training do you think needs to be improved 4.3.2.2.4 Category: Clinical Support The participants expressed concern over the lack of support in some of the clinical areas of placement in contrast with the warm welcome that they received on initial introduction to the units. The lack of support was greatly linked to shortage of clinical staff therefore students had to work without direction over allocated activities based on the clinical objectives for the programme and also missed learning opportunities. 125  Analysis, presentation and description of the research findings 2016 “...I can say we have many specialists that are determined want to teach Us[the students] , is like there is no time isn’t it learning is continuous, one can learn whilst working...” “...You [the student] can sometimes see that the clinical staff wants to teach you something but there is no time. That is still the challenge (laughter) ...” Discussion: The participants in a study by Henning et al (2011: 86) reported that the absence of pedagogical and psychological support in the learning environment reduces the quality of life and increase the risk of compassion fatigue and vicarious trauma on students. Part of the problem may rest in the relative importance of relationships as viewed by students and clinical staff. Rodger et al (2011: 98) found that while students identified a welcoming learning environment as an indicator of quality, clinical staff tended to focus more on operational requirements. The clinical learning environment is described by Smedley and Morey (2010:76) as a supportive community of practice where learning processes are underpinned by a culture in which “social interaction is a vital component, a place of cooperation, kinship, caring, support, understanding, unity and inclusiveness”. Results in this research have demonstrated that when students feel part of the team practice, their learning and satisfaction is increased. A good learning situation is regarded as one that is variable and should correspond to the particular expected educational needs of the students to achieve the learning objectives (Bisholt, Ohlsson, Engstrom, Johansson & Gustafsson 2014:308). To strengthen support amongst nurse educators and professional nurses should work together as a team, particularly when students are present in the clinical setting (Carlson, Pilhammar & Wann-hansson 2010:436). The students appreciated support that was offered by staff as it appeared to instill a sense of feeling valued and respected as a student (Boughton, Halliday & Brown 2010:35). Advantages related to collegial support and team work in the clinical setting include a reduction in the workload when it comes to patient care (Carlson et al., 2010:436). It will further enable 126  Analysis, presentation and description of the research findings 2016 professional nurses and students to spend more time together when engaging in valuable learning experiences (Carlson et al., 2010:436; Henderson, 2011:4). How do you prefer the clinical practice of the programme to be offered? 4.3.2.2.5 Category: Clinical supervision It is widely recognised by the participants that the transition from students to becoming qualified emergency nurse practitioners can be a stressful time that requires support and time. Lack of supervision over the clinical practice is a challenge that was noticed by participants as a delay in the students’ learning progress. The participants recognised that lack of supervision, teaching and learning support led to creation of a gap between the relationship of learned theoretical content and what is expected in clinical practice. Participants felt abandoned by the nurse educators during clinical placement due to lack of clinical accompaniment. Through clinical accompaniment the learning opportunities are created that enable the nursing students to develop from passiveness to involvement and to independent clinical practice. The process requires that the nurse educator be physically present so as to guide and oversee the learning experience of the learner whilst making use of various learning resources. Clinical accompaniment can be done through mentoring and preceptorship and clinical facilitation. “...I [the participant] think the professional nurses who works in that unit is the best candidate for the job to supervise the students because the person will always be there for continuous monitoring...” “...We had only one lecturer responsible for teaching and to accompany us for the purpose of supervision in the different wards where we were allocated...” “...I [the participant] also support this thing of clinical facilitator because there are these procedures in the clinical areas that are scares so if the facilitator is there and the students will be called to observe the procedure...” 127  Analysis, presentation and description of the research findings 2016 Discussion: Health Workforce Australia’s Clinical Supervision Support Framework (HWA 2011) defines ‘clinical supervision’ as the process whereby supervisors oversee either directly or indirectly professional procedures and/or processes performed by a student or a group of students within a clinical placement for the purpose of guiding, providing feedback on, and assessing personal, professional and educational development in the context of the student’s experience of providing safe, appropriate and high-quality patient care (HWA 2011:4). The nurse educator as supervisor manages the educational process purposefully and plans the necessary clinical education and clinical accompaniment (Muller 2011:347). Students have reported the supervisory relationship to be one of the most important factors influencing the students’ satisfaction within the clinical learning environment (Koontz, Mallory, Burns & Chapman 2010:244). Good supervisory relationships maintain a balance between the challenges posed to the student by the complexity of the programme and the clinical support provided through constructive dialogue and feedback (O'Donovan Halford & Walters 2011:106). There are several characteristics of supervisors that have been identified by Kilminster, Cottrell, Grant and Jolly (2007:15) as well as Våågstool and Skooien (2011:76) as desirable to enable effective supervision. The characteristics include ability to form positive relationships and rapport with students, being consistent and transparent in assessment of procedures, demonstration of clinical competence, being a good organiser and communicator, possessing strong leadership and management skills and acting as a role model who displays enthusiasm and a passion for learning.  Sub-category: Mentoring and preceptorship and clinical facilitation The students verbalised that they do not have mentors in the units of exposure to guide them. The participants could not demarcate between a mentor, preceptor and clinical facilitator so the words were used interchangeably. The participants are of the opinion that preceptors will be of value to guide the students in the clinical practice as they are always available in the units. It was indicated that during basic training, it has been the responsibility of the clinical preceptor to give learning support to students whilst in clinical placement. With the current practice there are no preceptors in the 128  Analysis, presentation and description of the research findings 2016 clinical areas and according to the participants the nurse educators are not always available in the units to guide them. Students are viewed as part of the workforce as most of the time emphasis is placed on getting the job done than considering the students’ learning process. This kind of experience was viewed as depriving the student from correlating theory to clinical practice as expressed by the participants. “...I [the participant] think is better if amongst the lecturers one is chosen, who mentor the students...” “...I [the participant] wanted to add even the programme still need someone who will monitor the programme, like a preceptor like they appoint preceptors from those different hospitals are used for training, it will be much easier in terms of the experience required for this course [programme]...” “...whenever you [the students] are doing exposure you must have a preceptor there in the unit who guides students...” Discussion: The Nursing and Midwifery Council (NMC) (2008:45) defines a mentor as the person who facilitates learning, supervises and assesses students in a clinical environment or practice setting. The responsibilities of a mentor are to make sure that the students have met the defined outcomes of a programme of study in the clinical area (Wigens & Hearthershaw 2013:38). Effective mentoring requires the creation of an effective learning environment by a mentor who has knowledge on the individual needs and requirements of the students and to be able to create an atmosphere conducive to learning (Ousey 2009:177). Mentors create a supportive and receptive environment that, in turn, enables students to air and address their anxieties (Pritchard & Gidman, 2012:120). Further mentoring characteristics identified through literature review include: being approachable, passionate about teaching nursing students, keeping communication channels open, providing positive and constructive feedback, adopting a structured 129  Analysis, presentation and description of the research findings 2016 teaching process, acting as a role model, and teaching clinical skills and critical thinking (Warren 2010: 165). In clinical institutions preceptorship is put into practice for teaching, counselling, inspiration and support of the growth and development of the student nurse (Wigens & Heathershaw 2013:65). According to Biggs and Schriner (2010:318) preceptors have to instil confidence in nursing students and empower them in skills practice in clinical areas. The authors further emphasise that preceptors have to also be knowledgeable about the programme so that they provide guidance to enhance students’ knowledge, skills and problem solving abilities whilst providing a link between theory and clinical practice. The provision of preceptors in specialized areas would be valuable in the attaining of students’ objectives (Warren 2010:10). 4.3.2.2.6 Category: Acquisition of clinical skills. The participants agree that intervention with clinical staff members during report taking, resuscitation, rounds and patient presentation exposed them to observing clinical skills although it was not adequate. The participants expressed concern over lack of equipment in the clinical environment and skills laboratory. The skills laboratory is regarded by the students as a safe area to practice skills that are scarce to find and risky for initial practice on the real patient. Some of the skills that are indicated by the participants are not easily implemented due to the scope of practice that is limited for emergency nurses like prescription of drugs before intubation. “...I [the participant] think if things are going accordingly they must hire a clinical facilitator or preceptor who will be each and every day in the ward to guide the students on how to perform procedures...” Discussion: Muller (2011:332) perceives student nurses as adult learners who will show learning readiness when they experience a need and a desire to learn something new to equip themselves better in the management of real life situations. Likewise, Crotty (2010:51) states that the learning experience is favoured by the atmosphere where it occurs. The author further relates the effectiveness of learning to different factors, one of which is personal perspective where the atmosphere permits acceptance of person, respect towards the person and support given to the person. In 130  Analysis, presentation and description of the research findings 2016 clinical setting this is equated to the students who are already professional nurses, come in with their own life experiences and build on what they already know. Guhde (2010:387) emphasizes that patients’ conditions became more complex and suggest that students need more effective learning opportunities in simulation and adequate clinical exposure.  Sub-category: Simulation The participants believe that when skills practice is done with procedures that are risky like insertion of a central venous line, intubation and cricothyroidotomy, it should first be simulated before it is done on real patients to enhance theoretical learning. “...They (Nurse Educators) demonstrate to us [the students] and then there after evaluate the students on what was demonstrated...” “...It depends on the type of the procedure if it is possible for you [the student] to do on the real patient but if it is not possible then simulation is necessary...” “...Most of the procedures which are in our workbook can be more of hazard if the person [the student] does not do them well for example insertion of a central line...” “...I [the participant] think doing the procedures not necessarily requires a live person but then still on that note we [the students] don’t have the models that we can use to simulate...” . “...The cadavers are there for learning if they are requested for that purpose. If you [the students] can’t have a live person you can have the cadavers to simulate... . “...like you only see cricothyroidotomy when you do Advanced Trauma Life Support (ATLS) and is not everybody who is doing ATLS if you went for ATLS you can see it during simulation with cadavers...” “...in ATLS students need to have time for simulation and when you are with them (the doctors) and the procedure is observed and explained it is simpler, and there is time to ask questions…” “...one other thing is lack of equipment at the college whereby sometimes we [the students] need to see a video on resuscitation; such equipment is not available...” Kaphagawani and User (2013:182) indicate that simulation has become an integral part of nursing education with increasing numbers of students and decreasing 131  Analysis, presentation and description of the research findings 2016 numbers of available clinical sites. The authors further emphasize that learning takes place when students apply what they have learned in classroom situation and practiced in a simulation laboratory into the reality of nursing. There are different types of simulation used in nursing education which include but are not limited to computer assisted instruction, standardised patients, virtual reality, low fidelity to high fidelity mannequins (Decker, Portsman, Puetz & Billings 2008:86). The study conducted by Swenty and Eggleston (2010:e186) indicated that students value fidelity and expect the simulation to be as real as possible for integration of multiple concepts within a scenario. The study revealed that regular scheduled simulation experiences led to increasing the students’ comfort levels giving patient care which was reflected in self-confidence and satisfaction. Many current simulation models can be used to enhance the development of knowledge, skills and attitudes needed to practice emergency medicine to enable students to recreate life threatening emergencies and practice lifesaving invasive procedures (Raymond & Ten Eyck 2011:11). The authors believe that simulation readily accommodates the focused, repetitive practice of patient care skills and behaviours.  Sub-category: Partnership with institutions outside the Limpopo province All participants reported that their knowledge on emergency care, responsibility, leadership and teaching had developed although they completed the programme without being exposed to some of the procedures that were scarce. The participants propose the outsourcing of the clinical skills that are scarce within the province at other institutions out of the province, as it was done with the initial groups to acquire the expected clinical competency for emergency practice. “...some procedures are seen during exposure and after that you [the student] will never see them again during training... we are also loosing opportunity of recording in the workbooks...” “...there are procedures that are rare or scares which we may not see until the end of the course...” “...like we [the participant] never saw crico-thyroidotomy...” 132  Analysis, presentation and description of the research findings 2016 “...Yes but because there are so many procedures that they don’t do this side [in the province]...” “...Some of the procedures are not seen because they [the procedures] are not done in hospitals that we[the participants] come from, maybe they are done in bigger hospitals...” “...or maybe we [the students] can go to hospitals like Ga-Rankuwa...” “...Well I can suggest that maybe if we can be placed in in Jo’burg [Gauteng province hospital] for a month....” “...With such cases they need to arrange students to go and be with them [the nurse educators] where such cases are regularly seen...” Discussion: Nursing Education Institutions have to reflect successful partnerships with the academic institution where their programmes are located, with other disciplines, with clinical sites, with clinical and professional organizations and with international partners (Nursing Education standards 2005:24). Decker et al (2008:74) agree that competency in nursing involves the acquisition of relevant knowledge, the development of psychomotor skills and the ability to apply the knowledge and skills appropriately in a given context.  Sub-category: Scope of practice The participants felt the need for the South African Nursing Council to develop the scope of practice for emergency nursing as well as delineating core competencies. Overall, the responses indicated that the scope was too limited as there is no line of demarcations for general professional nurse from advanced emergency nurse practitioners; qualifications were perceived as making no academic difference although lives were saved in the clinical practice. The responses indicated satisfactory knowledge and skills with regard to emergency procedures required for care of regular emergency conditions that are presented to the emergency departments. They also expressed dissatisfaction with the fact that the practice is limited despite the competency. 133  Analysis, presentation and description of the research findings 2016 “...we learn how to intubate a patient to save patients’ lives, you[the student] cannot give the patient drugs , but you can intubate so our scope of practice is sort of limited ... you [the students] are unable to perform those procedures but you need somebody to come and prescribe drugs before intubating the patient...” “...I [the participant] think if maybe they [the South African Nursing Council] can sort of... increase the scope of practice or maybe introduce a course in pharmacology so that we can be given a chance to prescribe and to execute some of the procedures when the doctor is not available...” “...without relevant prescription course, the emergency nurse cannot give the patient drugs , although can intubate,... the scope of practice is sort of limited...”. Discussion: The scope of practice for the professional nurses is delineated by the South African Nursing Council (SANC) in the Nursing Act 2005 Section 30 as a regulating body and it incorporates the actions and responsibilities of the individual nurse practitioner for professional practice to promote excellence in clinical practice. The scope of practice generally refers to the broad range of activities that nurses perform and manage in the delivery of care to prevent unlicensed professionals from providing services that are reserved to licensed professionals (Urden et al 2014:31). The emergency nursing students perceive the ability for trained emergency nurses to treat presenting conditions in their own capacity as the strong factor to determining their scope of practice (McConnell, Slevin & McIlfatrick 2012:80). The authors further believe that the development of emergency nurse practice roles will result in a broader complexity of the role as evidenced in advanced decision making skills that the practitioners are involved rather than adherence to protocols that are set for less experienced nurses with limited care which may not be synonymous with advanced nurse practice. Most care delivered remains protocol-led, signifying little autonomy for practice, standardisation of education, role and scope of practice could reduce the need for protocol led care leading to a more autonomous role (McConnel, Slevin & Mcllfatrick 2012:82). The SANC under the provisions of the Nursing Act of 2005 is currently in 134  Analysis, presentation and description of the research findings 2016 the process of developing the competencies for specialisation fields, emergency nursing is amongst the critical care nurse specialists. The competencies are outlined according to the following domains: professional, ethical and legal practice, care provision and management, quality of practice, management and leadership and research (SANC competencies for critical care nurse specialists 2014). 4.3.2.2.7 Category: Students residential area The participants argue that the residential area for students need to be separated from other health professionals that are not currently involved with studies as there are a lot of disturbances like loud music noises along the passages from those individuals. The other negative impact is unavailability of study areas. “...I [the participant] think the issue of residence mixing with staff and those students who are doing basic course also disturb us [the post basic students] in a way because they [the basic students] always make noise, play loud music. There is no place to study like a library during the night because in the rooms they are making noise and that disturbs studies. Maybe if the residence can be divided...” Discussion: Accommodation is described by Snyder, Kras, Bressel and Reeve (2011:1) as a housing option, a residential area or a place of residence which on the part of the student nurse could be around or outside the school vicinity. Paltridge, Mayson and Scapper (2010:353) mention that accommodation at Australian universities varies from fully-fledged to non-catered, from student staying communally, namely each one having their own private bedroom but sharing the kitchen, recreational areas, a dining room, a bathroom, to the type of accommodation where students live independently. In the study by Jafta (2013:129) on perceptions of tutors and students on factors that influence academic performance at a nursing college there was poor control from college authorities. Neither the head of the college or the residential committees interfered when students complain about a lack of rest due to partying, or noisy behaviour by students who are not writing tests, or those who are not taking their studies seriously. This had a negative impact on students’ learning. 135  Analysis, presentation and description of the research findings 2016 4.4 OVERVIEW OF RESEARCH FINDINGS The findings on the views of the students with regard to aspects of theoretical learning and clinical practice were taken into consideration and analysed according to the phases of Appreciative Inquiry based on the interview guide. 4.4.1 Discover the “best of what is” The participants had positive theoretical experiences that led to increased knowledge and adequate curriculum content. The preregistration exposure, student’s selection criteria and the nurse educators’ character were regarded as valuable aspects for best practice. The participants also had positive clinical experiences in the clinical area. The pre-registration exposure period served as orientation to the programme. The good relationship with clinical staff members, as well as interprofessional teamwork that guided their practice, helped improve competency in clinical skills. The negative experiences included shortage of nurse educators, classrooms and study materials in theoretical learning. The teaching and learning strategies that were utilised included discussion method programmed learning and interprofessional education. The participants felt that the nurse educators did not give immediate feedback to students. The attitude of some of the nurse educators was unpleasant. The clinical experiences indicated inadequate clinical exposure, shortage of clinical personnel—an experience that left the students with anxiety and frustration when students are used as workforce to cover for the shortage. Placement of students at the Emergency medical services was not meaningful to the students 4.4.2 Dream “what could be” The participants identified that some of the nurse educators did not have adequate current knowledge on the content and required to be updated through continuous professional development. The students are of the opinion that adequate clinical exposure and support is required to appropriately orientate the students into the activities required in emergency practice. The participants allege that the scope of 136  Analysis, presentation and description of the research findings 2016 practice of the emergency nursing is so limited and does not match the skills that the students are taught in practice. 4.4.3 Design “what should be” The participants put forth the ideas and changes which, when implemented, will serve to sustain the positive transformation of the programme. The findings speculate that formalised pre-registration package can improve the students’ performance and also guide college management with the selection of students for enrolment into the programme. The participants envision approval of study leave and research proposal for post-basic programmes by the Limpopo Department of Health be revisited for better timing of approval. The academic training period is argued by the participants’ as minimal for completion of the expected clinical skills. Mentoring, preceptorship and clinical facilitation should be implemented to improve the quality of education and training. Residential areas need to be appropriately designed to support the learning process of students. The scope of practice for emergency nurses requires revitalisation by South African Nursing Council with contributions from the emergency nurses. 4.5 CONCLUSION Chapter 4 presented an analysis of the data in terms of the themes, categories and subcategories that the researcher indentified in data analysis. The findings were supported by literature for conclusions reached in this chapter to confirm the identified themes, categories and subcategories for this study with regard to the views of students on the Emergency nursing programme training offered at the Limpopo College of Nursing. Chapter 5 sets out the conclusions and recommendations as defined in the Destiny phase of Appreciative Inquiry and limitations for this study. 137  Conclusions and recommendations 2016 CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS 5.1 INTRODUCTION In chapter 4 data analysis and interpretation was presented with reviewed literature control. In this chapter the researcher will concentrate on the conclusions, limitations and recommendations for the proposed strategies in this study to address the identified challenges for an ideal theoretical and clinical practice of Emergency nursing. 5.2 RESEARCH DESIGN AND METHODS A qualitative research design was employed to conduct the study. An explorative descriptive design utilising the Appreciative Inquiry approach was used to answer the research questions based on the interview guide. A purposive sampling was conducted as the participants with experience on the training of emergency nursing were selected from the health institutions around the Limpopo Province. The sample comprised of twenty professional nurses who were trained for the Emergency nursing programme at the Nursing Education Institution in the Limpopo province from 2008 to 2014. Focus group interviews were conducted by an independent facilitator following the interview guide (View Annexure D). This eased the independent facilitator into questioning. Focus groups provide opportunities for brainstorming and is considered to be highly effective in generating rich data which is further enhanced by the interaction between the group members (Polit & Beck 2012:538). Data collection was done in a natural setting at a learning center in one of the accredited institutions for training, away from the daily activities of the institution. The participants were well informed about the study, voluntary participation and informed consent forms were signed prior to conducting the focus group interviews. Privacy and anonymity of the Nursing Education institution and participants was maintained throughout the process of data collection, and the participants’ names were not utilised. The collected data was transcribed and the themes for analysis were 138  Conclusions and recommendations 2016 organised and formulated. The results emanating from the collected data were presented in the preceding Chapter. 5.3 SUMMARY AND INTERPRETATION OF RESEARCH FINDINGS DISCOVER THE “BEST OF WHAT IS” During the discovery phase the participants had to response to the question: “Tell me a story about the best theoretical experience that you had as a student in the education and training for the emergency programme. 5.3.1 Expanding our knowledge and understanding The participants indicated that the theoretical aspect was interesting as the content was quite challenging and engagement stimulated critical thinking. The categories that emerged under theoretical aspects included positive theoretical experiences, increased knowledge and relevant curriculum content. 5.3.1.1 Positive theoretical experiences The positive experiences that the participants had are related to increased knowledge and the composition of the appropriate curriculum content. The participants’ experiences during exposure in the programme indicated increased knowledge in the management of emergency patients and acceptance of the curriculum content as relevant and of high standard. 5.3.1.1.1 Increased knowledge Participants positively perceived that by undertaking new learning approaches, they had opportunities to foster academic and cognitive learning skills, increased knowledge acquisition and also believed that the intensity of the programme encouraged them to increase their responsibility and autonomy for their independent learning. All the participants affirmed that exposure to the programme engaged them in acquisition of new knowledge and skills for the application of quality care. 139  Conclusions and recommendations 2016 5.3.1.1.2 The curriculum content The curriculum content was perceived as relevant for the complexity of the programme. The participants ranked the programme as being of a high standard that enabled the professional nurse to practice independently and responsibly based on the amount of knowledge gained. The curriculum content is an important aspect of quality education and therefore should be relevant to the needs of the community it serves to equip the students with relevant information. Elaborate on the aspects of theory that are valuable for success in the programme. 5.3.1.1.3 Motivation to learn The participants were motivated by the welcome and the practice that was observed during training, feelings towards task performance as well as the ability to make independent decisions. Motivation led to students’ higher levels of success, self- regulatory control with the outcome influencing future motivation. The teaching role that the professional nurses and medical personnel took upon themselves every day to impart knowledge to the students during in-service training and performance of emergency procedures in the unit was valued. 5.3.1.1.4 Nurse educators’ characteristics The participants in this study portray the Nurse Educators as knowledgeable, approachable, supportive and passionate. A good relationship with students motivates students to learn. The nurse educators were regarded as the most important resource in the education and the most influential factor in the learning situation for training and education. Tell me about the challenges that you met in theoretical learning 140  Conclusions and recommendations 2016 5.3.1.2 Shortage of resources The participants expressed concern on the shortage of resources required for the smooth running of the programme. Shortage of resources included nurse educators, classrooms and study materials. Learning takes place when a student is provided with a variety of learning resources that offer exposure to other opinions that assist in promotion of learning. 5.3.1.2.1 Shortage of Nurse Educators In the findings for this study, the participants reported that shortage of staff was a major challenge that prevented the efficient theoretical learning and rendering of adequate healthcare service. The participants’ verbalised shortage of lecturers as a problem that unduly delayed learning. Quality nurse education is impossible if the quality and quantity of supportive nurse educators is inadequate. 5.3.1.2.2 Classrooms and desks The participants reported that there is no classroom available for the emergency programme in the college premises. The participants believe that the Department of Health must be held responsible to make resources available for quality nurse training as emphasised in the Nursing Education and Training Standards. 5.3.1.2.3 Study materials The participants in the programme experienced late provision of study guides and workbooks at the beginning of the programme and this experience was seen as a delay in studying the expected learning objectives and completion of clinical records. DREAMING “WHAT COULD BE” Elaborate on the aspects of theory that are valuable for the success in the programme? 141  Conclusions and recommendations 2016 5.3.1.3 Orientation The participants reiterated on the importance of being orientated into the theoretical expectations of the programme through the pre-registration package before they are enrolled into the programme. The findings speculate that a formalised pre- registration package can improve the students’ performance and also guide college management with the selection of students for enrolment into the programme. DESIGNING “WHAT OUGHT TO BE” Imagine yourself as the facilitator in the programme: Which aspects in theory will you change to refine the programme? 5.3.1.4 Acquisition of theoretical knowledge The participants reported increased confidence from completing the programme as well as feeling more assertive with increased knowledge and skills to challenge the practice. The confidence attained from the training was regarded by the participants as integral to career advancement. The increase in knowledge and skills was believed to have an influence on increased credibility and autonomy in the practice setting and an increase in job satisfaction. 5.3.1.4.1 Teaching and learning strategies The participants reported the utilisation of varied teaching and learning strategies in the programme, and in some instances was dependant on the choice of the student during self-study. Most of the participants reported satisfaction with the discussion method as the student has to come prepared for the session and therefore became the responsibility of the students to work on their own so that they improve understanding of the content on the current study. The students emphasised active participation on the part of the nurse educator to guide and correct the students during discussion. The participants found the discussion and use of scenarios demanding and required students to reflect actively on their previous and current knowledge and experience 142  Conclusions and recommendations 2016 in the meaning making process on the theoretical content. The participants indicated that the discussion method and programmed learning sometimes left them in the dark when the educator was not actively involved. The participants seemed comfortable with a transmission mode of teaching, and that it was a huge shift for students to adopt more active learning approaches and to find footing in adult learning that promotes active critical thinking. Mutual identification of a learning approach with individual students is regarded by the participants as the best method for facilitating reflective, autonomous practitioners to bridge the gap between theoretical and practical knowledge more especially that most of them were not currently engaged with studies for long periods of time and they needed time to adjust to the pace of learning. 5.3.1.4.2 Feedback The participants indicated concern on failure by lecturers to give immediate feedback after every formative assessment. Feedback is one of the fundamental activities in teaching and requires nurse educators to make it positive, clear and constructive with a focus on acknowledging the students’ successes and correcting the incorrect answers. All told, it hones an approach to questions with the aim of guidance towards future improvements to enable students to make their own revisions to gain new understanding. 5.3.1.4.3 Nurse educators’ attitude towards students The attitude of some of the Nurse educators towards the students is perceived undesirable. The participants demand respect and positive regard from the nurse educators. The participants indicated that correct information needed to be availed by the nurse educators in cases where the students went an extra-mile to look for relevant information to the content at hand rather than ridiculing the student based on inadequate knowledge. Occasional late coming by the Nurse Educators was also experienced and sometimes delayed the process for the day. Good relationships are important to students because of the support and sense of belonging they provide. 143  Conclusions and recommendations 2016 5.3.1.5 Continuous professional development The participants identified that some of the nurse educators did not have adequate current knowledge on the content and required an update through continuous professional development. Lack of adequate knowledge was related to the argumentative behaviour as displayed by some of the nurse educators. Based on this defensive attitude on the part of Nurse Educators, the students mentioned the development of anxiety and fear of consulting the Nurse Educators in instances where the content at hand was not well understood. The participants expect nurse educators to have knowledge and skills that the student do not have, be up-to-date with the subject matter that they are expected to teach and know how to communicate the knowledge to the students. DELIVER “WHAT WILL BE” How do you prefer the theory to be improved? 5.3.1.6 Rules and regulations regarding training The participants argue on the practice of how the approval of study leave is granted by the Provincial Health Department. The study leave application is expected to be approved in time to allow time for the students to prepare themselves physically and psychologically for the study. The academic training period as stated in the curriculum approved by the South African Nursing Council (SANC) was experienced as being short based on the large amount of content and skills to be acquired within the 12 months period. 5.3.2 Delivering the practice in the clinical setting DISCOVER THE BEST OF “WHAT IS” 144  Conclusions and recommendations 2016 Share the most exciting peak experience that you had as a student in the clinical area during your training for the Emergency programme. 5.3.2.1 Positive clinical experiences The participants indicated appreciation, satisfaction and improvement in the practice of emergency care. Effective clinical placement can improve nurses’ competency as such, during clinical placement the students reach a level of confidence to handle different situations and realise expectations and objectives for the particular area. Gaining clinical experience was stated by the participants as one of the main factors that enabled students to survive working in emergency and intensive care departments. The participants explained that these positive experiences made it easier for students to deal with the patients, staff and the multidisciplinary team members both physically and psychological. The clinical experiences enhanced the students’ feelings of confidence in dealing with patients requiring emergency care. These positive emotions included feelings of reward and satisfaction as well as making a difference in their practice. Which aspects do you value in the clinical practice of the programme? 5.3.2.1.1 Relationship with staff The participants agreed that they had good relationships with clinical staff. Good relationships created better opportunities for learning, support and clinical practice improvement and that was found to facilitate learning. The clinical knowledge gained was utilised at the participants’ respective institutions at the rural areas where there is always shortage of medical doctors to save lives of patients presenting with emergency conditions. 5.3.2.1.2 Competency in clinical practice The findings in this study indicate that the participants perceived their own capacity to treat the presenting emergency conditions as the strongest factor in determining 145  Conclusions and recommendations 2016 their scope of practice. This indicates that the participants felt that they had control over their role by virtue of the acquired knowledge and skills in the emergency practice. 5.3.2.1.3 Interprofessional teamwork The participants reported positive relationships with other health care teams in the management of the critically ill and injured patients in all environments of clinical placement. It was indicated that they exchanged knowledge in interventions that were geared to improve the patients’ conditions. That, in turn, created the maintenance of a climate of mutual respect and shared values. Tell me about challenges experienced in the clinical area during training? 5.3.2.2 Negative clinical experiences The participants reported that sometimes in critical care units there was lack of support, as the students were given patients to nurse on their own, used as workforce based on shortage of personnel and that increased workload and reduced learning opportunities. Placement of emergency nursing students is done in the following areas: Emergency care unit, Intensive care units (general, cardiac and pediatric) burns unit, operating theatre and renal unit to expose the students to holistic care of patients with emergency conditions. 5.3.2.2.1 Inadequate pre-exposure period The participant mentioned that pre-exposure period of four months is inadequate and of no value if not utilised effectively. The participants reckon pre-exposure period is an important time for orientation of students to the programme if not only utilised for clinical practice, but also important for theoretical aspects of learning. Adequate exposure period is regarded as valuable for students to have an idea of the complete expectations within the programme. 146  Conclusions and recommendations 2016 5.3.2.2.2 Shortage of clinical personnel The participants in this study emphasised that shortage of personnel at the clinical environment resulted in missed learning opportunities and lack of support at the clinical environment. Clinical accompaniment by nurse educators was minimal and it was also related by the participants to be a consequence of shortage of personnel. 5.3.2.2.3 Students as workforce The students were utilised by the institutions as workforce to supplement for the shortage of clinical personnel, and there was no time allocated for clinical teaching. When students are utilised as workforce their role as learners is disregarded and replaced by completion of routine work in the units of which the outcome is elevation of stress levels. 5.3.2.2.4 Anxiety and frustration The participants experienced anxiety and frustrations as an outcome of poor support. Initial clinical experience especially in the Intensive Care Unit was the most anxiety producing part of the students’ clinical experience as they had fear of making mistakes and doing harm to the patients on manipulation of various monitoring equipment around the patient of which they had no skill to operate them. Anxiety and frustration created some form of disruption to the normal functioning where some of the participants even thought of taking sick leave days. 5.3.2.2.5 Theory and practice gap The participants experienced a gap between the theory that was learned in classroom and the reality in the practice of emergency care. That was especially observed in clinical learning areas. The practice of clinical skills without support from experienced staff is viewed by the participants as compromising the patients’ safety, particularly because procedures are done without constant supervision. 5.3.2.2.6 Clinical placement in the Emergency Medical Services Some of the students did not understand the reasons for allocation in the pre- hospital environment as the activities were seen as a duplication of primary survey of patients that was done in the emergency units. The participants argued that they 147  Conclusions and recommendations 2016 were constantly allocated under the supervision of junior personnel below the level of the professional nurses’ practice and did not acquire any clinical skills. DREAM “WHAT COULD BE” Which aspects in clinical training do you think needs to be improved or refined? 5.3.2.3 Clinical support The students are of the opinion that adequate clinical exposure and support is required to appropriately orientate the students into the activities required in emergency practice. The lack of support was greatly linked to shortage of clinical staff therefore students had to work without direction over allocated activities and also missed learning opportunities. 5.3.2.4 Clinical supervision Lack of supervision over the clinical practice is a challenge that was noticed by participants as a delay in the students’ learning progress. The participants recognised that lack of supervision, teaching and learning support led to the creation of a gap between the relationship of learned theoretical content and what is expected in clinical practice. Participants felt abandoned by the nurse educators during clinical placement due to lack of clinical accompaniment. 5.3.2.4.1 Mentoring and preceptorship and clinical facilitation The participants are of the opinion that preceptors will be of value to guide the students in the clinical practice as they will always be available in the units. The participants could not demarcate between a mentor, preceptor and clinical facilitator so much so that the words were used interchangeably. There are no preceptors in the clinical areas with the current practice. Students are viewed as part of the workforce as most of the time emphasis is placed on getting the job done than considering the students learning process. 148  Conclusions and recommendations 2016 DESIGNING “WHAT OUGHT TO BE” How do you prefer the clinical practice of the programme to be offered? 5.3.2.5 Acquisition of clinical skills The participants expressed concern over the lack of equipment in the clinical environment and skills laboratory. The skills laboratory is regarded by the students as a safe area to practice skills that are scarce to find and risky for initial practice on the real patient. 5.3.2.5.1 Simulation The participants believe that when skills practice is to be done with procedures that are risky like insertion of a central venous line, intubation and cricothyroidotomy, simulation should be done before the skills are practiced on real patients to enhance theoretical learning. The simulation idea was supported by participants with experiences from the advanced Trauma life support, where procedures were done with simulation on high fidelity mannequins and cadavers. 5.3.2.5.2 Partnership with institutions outside the Limpopo province The participants reported that their knowledge on emergency care, responsibility, leadership and teaching had developed although they completed the programme without being exposed to some of the procedures which were scarce. 5.3.2.5.3 Scope of practice The responses indicated that the scope of practice for emergency nursing is too limited as there is no line of demarcation for general professional nurse from advanced emergency nurse practitioners. Qualifications were perceived as making no academic difference although lives were saved in the clinical practice. The responses indicated satisfactory knowledge and skills with regard to emergency procedures required for care of regular emergency conditions that are presented to the emergency departments although the practice is limited despite the competency. 149  Conclusions and recommendations 2016 5.3.2.6 Students residential area The participants argue that the residential area for students needs to be separated from other health professionals that are not currently involved with studies as there are a lot of disturbances like loud music and noises along the passages. The other negative impact is unavailability of study areas. 5.4 CONCLUSIONS The overall aim of the study was to evaluate the Emergency nursing programme offered at the Limpopo College of Nursing based on the student’s views. The conclusions are based on the objectives according to the Appreciative Inquiry process utilised in this study to achieve the purpose. The objectives of the study were to:  Explore and describe the views of post-basic students pertaining to the theoretical component of the emergency nursing programme.  Explore and describe the views of post-basic students pertaining to the clinical component of the emergency nursing programme.  Suggest strategies for the refinement of the theoretical of the emergency nursing programme.  Suggest strategies for the refinement of the clinical component of the emergency nursing programme. The findings on the views of the students were considered and arranged according to the formulated themes, categories and sub categories with regard to aspects of theoretical learning and clinical practice as a base of focus to formulate conclusions and to make final recommendations to address the purpose for the study. According to the researcher the participants had both positive and negative experiences on the theoretical and clinical aspects. Explore and describe the views of post-basic students pertaining to the theoretical component of the emergency nursing programme. 150  Conclusions and recommendations 2016 5.4.1 Theoretical aspects Experiences on theoretical aspects triggered the utilisation of critical thinking in the classroom and in clinical areas where quick decision-making is required to save the lives of the critically ill and injured patients. The increased knowledge and skills that were verbalised by the students were also utilised during patient and lecture presentations that were held in their areas of clinical placement. The Nurse Educators characteristics are regarded as valuable for better communication, coordination, competency and quality of care that is required from the nurse practitioners in this field of study. Based on the findings with regard to learning strategies the participants struggled on the utilisation of suitable strategies for individual learning without guidance from the nurse educators as indicated in the responses. The researcher identified that positive experiences can have an influence on the performance of the students and therefore the quality of emergency care. Challenges like negative attitudes by the Nurse Educators towards the students and lack of human and material resources limited the learning opportunities for students as some of the procedures were not regularly done in the accredited institutions but rather referred to advanced institutions in the Gauteng province. Explore and describe the views of post-basic students pertaining to the clinical component of the emergency nursing programme. 5.4.2 Clinical aspects The participants had good relationship with clinical staff. The clinical objectives for the students as professional nurses were to acquire knowledge and skills to find a balance between independent practice, leadership and collaboration within the interprofessional health team. The participants gained a lot of clinical practice from coordination with interprofessional teamwork and that improved competency in te area of clinical practice. 151  Conclusions and recommendations 2016 The pre-registration clinical exposure period was minimal and therefore was perceived as having no value to students that were from the rural institutions. Shortage of clinical personnel resulted in the utilisation of students as workforce and lack of support for clinical learning was evident. The employee status of post- registration students contributed to the fact that emphasis was placed on meeting the service need rather than on students learning. Initial clinical experience especially in the Intensive Care Unit was the most anxiety producing part of the students’ clinical experience as they had fear of making mistakes and doing harm to the patients on manipulation of various monitoring equipment around the patient of which they had no skill to operate them. The existence of the theory-practice gap is an issue of concern as it has been shown to delay the students learning. Integration of the theoretical and practical knowledge is a pre-requisite in clinical situations. Limited theoretical knowledge may raise difficulties for gaining practical knowledge whilst advanced knowledge without the opportunity for experiential learning as indicated in the responses could result in an inability to link the academic concepts or attach meaning to activities in clinical practice. The ability to link theory and practice was particularly important for the participants. There was lack of clinical support and supervision due to shortage of personnel. Unavailability of nurse educators for clinical accompaniment indicated a need for mentoring, preceptorship and clinical facilitators. Updating the theoretical knowledge should be followed with practical knowledge gained in clinical settings to assist the nurse to attach meaning to activities and apply the theoretical learning to practice. The acquisition of knowledge through clinical simulation and partnerships with other institutions was requested. The limited scope of practice for emergency nursing was of concern as it is in most instances protocol led rather than individual competency. The residential area was not suitable for learning. 5.5 RECOMMENDATIONS Suggest strategies for the refinement of the theoretical aspects of the emergency 152  Conclusions and recommendations 2016 nursing programme. 5.5.1 Theoretical aspects  The Nursing Education Institution should provide adequate human and material resources to improve the students’ academic performance needed for effective learning and clinical practice to take place, such as enough nurse educators, classrooms, study materials and well equipped libraries.  Study materials should be available on the first day of admission to give the students enough time to get acquainted with the content and the expectations of what to achieve at the end of each learning unit.  Teaching and learning of emergency nursing takes place in a highly contextual and variable environment. The participants believe that nurse educators should consider the utilisation of different teaching and learning strategies for teaching and learning to effectively take place. Nurse educators should possess attributes of competency and experience to identify those strategies that are working well for the type of students.  The participants advocate for the extension of the period of training to 18 months so that all learning shortcomings from the students are accommodated.  The inclusion of the specialists’ medical practitioners is requested for appropriate interprofessional teaching.  Feedback should be given immediately after each assessment as is considered a collaborative process between the student and the nurse educator to provide insight to learners about their performance.  The nurse educators should have a positive attitude for students to feel at ease to consult whenever necessary.  It is recommended that the Department of Health as the employer should take continuous professional development as a matter of high priority to ensure and sustain competent and knowledgeable Nurse Educators for the benefit of the Nursing Education institutions and the population at large in the practice of health care. 153  Conclusions and recommendations 2016  Study leave should be approved before the exposure period at accredited institutions for training and, during this period, the students can be given clinical objectives of what is expected in the programme.  A research report has to be presented within the academic training period.  Likewise, a pre-registration learning package has to be formulated, given to prospective candidate and formally evaluated to serve as part of admission criteria into the programme. Suggest strategies for the refinement of the clinical aspects of the emergency nursing programme. 5.5.2 Clinical aspects  Adequate clinical staff is required to take responsibility for providing learning support for students in the clinical areas.  The nurse educators should accompany the students to the various clinical areas to enhance practical learning. Mentoring, preceptorship and clinical facilitation are supervisory models recommended for the necessary support and guidance for students in the clinical area to enhance learning through provision of opportunities for learning.  Supervision at Emergency Medical Services (EMS) has to be done by personnel with relevant qualifications to support effective learning outcomes at pre-hospital areas.  Simulation in the clinical laboratory with advanced models to be implemented for emergency care skills that are risky to practice on real patients.  Partnership with other health institutions outside the province is required where students can be placed on exposure for scarce procedures.  Standardisation of the role and scope of practice by the South African Nursing Council to minimise the protocol led practice.  The residential area should be well organised in such a manner that the students have access to the library and or study area after hours. 154  Conclusions and recommendations 2016 5.6 LIMITATIONS OF THE STUDY The study was conducted in one Nursing Education Institution in the Limpopo Province so the findings cannot be generalised to other institutions. This study only evaluated the students’ views and not the whole programme. The researcher was known to the participants and this may have affected the students’ responses. 5.7 CONCLUDING REMARKS This chapter discussed the research design and methods used in this study, presented a summary and interpretation of the research findings and formulated conclusions. The recommendations arising from the findings to improve the theoretical and practical aspects in the education and training of Emergency Nursing, and contributions that this study can make in nurse education and training were stated. The limitations of the study were also indicated. The study provides evidence that education and training in the emergency nursing programme has mostly positive effects on the development of nurses in the practice of emergency nursing. Emergency nurses experiences a process of change during training with regard to thinking, assessment, analysis and clinical skills practice. The emergency nurses become developed on advanced knowledge through critical thought, reflection, assessment, analysis and clinical skills practice on a wider range. As a result, they also learn how to collaborate with other health care teams to reach an objective of saving lives. The change that is eminent in this study indicates the expansion of emergency nursing boundaries and the development of the scope of practice for emergency nurses in South Africa. Further research is recommended to identify the factors within the programme that will bring positive results to strengthen the education and training of the programme. 155  Reference list 2016 REFERENCE LIST Abelsson, A & Lindwall, L. 2012. The pre-hospital assessment of severe trauma patients’ performed by the specialist nurse in Sweden- a phenomenologic study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 20:67-74. Ali, P. 2008. 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APPLICATION FOR PERMISSION TO CONDUCT RESEARCH Department of Health Limpopo Province Polokwane 0700 Motseo P.I. 2810 Zone 2 Seshego 0742 Contact No. (0827566280) Dear Sir / Madam APPLICATION FOR PERMISSION TO CONDUCT A MASTERS RESEARCH STUDY AT LIMPOPO COLLEGE OF NURSING. I hereby kindly seek permission to conduct my Masters Research project at Limpopo College of Nursing. I am a student at the University of South Africa (UNISA).The proposed topic for inquiry is: Evaluating the Emergency Nursing programme presented at a Nursing Education Institution in the Limpopo Province: An Appreciative Inquiry. I have a copy of the research proposal, approval from the ethical committee from the university, as well as a copy of the participant information letter and appreciative inquiry interview guide for the proposed study. Limpopo Province is amongst the provinces with the highest mortality rate from motor vehicle accidents and emergency medical conditions. The province therefore requires adequate training of professional nurses in emergency nursing as a post basic speciality to aid in the management of such emergencies and helps reduce the mortality rate. Competent emergency nurses require quality education and training to ensure comprehensive skills in quality patient care. The nurse educators together with the nursing education institutions are responsible for evaluation of the quality of education and training of the programmes offered by the NEI as required by the South African Nursing Council to meet challenges of the ever-changing health care environment. 1  Student Nr: 4 3 7 3 6 7 3 4 The overall aim of the study is to evaluate the emergency nursing programme by means of Appreciative Inquiry to identify the challenges that require modification to create a collective vision of the center of excellence in the nurse training and education.The ethical considerations, which include: permission, confidentiality, anonymity and privacy will be maintained. The study will be beneficial to the community, the nursing education institution and the management of trauma and emergency medical conditions in the Limpopo Province. Hoping that my application will be considered. Your time, effort and support in this matter will be highly appreciated Motseo P.I. 2  Student Nr: 4 3 7 3 6 7 3 4 MOTSEO P.I. PARTICIPANT INFORMATION LEAFLET/ CONSENT FORM TITLE OF THE STUDY: Evaluation of the trauma nursing program presented at a nursing education institution in the Limpopo Province: An Appreciative Inquiry I am a student at University of South Africa doing a Masters degree in Health Studies (MA Health Studies). The intended study is part of the requirements for the completion of the Masters degree. Purpose of the study You are invited to take part in the study as a professional nurse trained for the additional qualification in the Critical Care Nursing: Trauma at the nursing education institution in the Limpopo Province. The overall aim of the study is to evaluate the Critical Care Nursing: Trauma post basic programme, by means of Appreciative inquiry research process with the purpose of refining the programme for future practice to meet the expected standard of quality education and training. To achieve this aim the specific objectives of the study are as follows: • To explore the views of professional nurses (trained in critical care nursing trauma programme offered at the nursing education institution in the Limpopo province) on the education and training of the programme. • To plan strategies for refining the theory and practice of the programme based on stakeholders recommendations. It is intended that findings from this study will be used in making recommendations to the nursing education institutions managers to contribute to the improvement in the education and training of the programme. 3  Student Nr: 4 3 7 3 6 7 3 4 Explanation of the procedures to be followed The request for your participation in this study is based on the experiences you had in training for critical care nursing trauma as an additional qualification. The Appreciative Inquiry process will be done through focus group interviews. The shared vision of what the programme should be will be of value for creation of innovative ideas and strategies to refine the programme. Risk and discomfort No form of health risk and discomfort is anticipated during the study.However, your input into this project will require your time and effort. Benefits of the study As a participant in this study there are no incentives put on the plan. The positive influences from participants are expected to improve the education and training of the programme as well as the practice in the health institutions. Voluntary participation in and withdrawal from the study Participation in this research is completely voluntary and withdrawal from the study is an exclusive right of the participants at any stage of the study. Ethical Approval The permission to conduct this study will be obtained from the Research Ethics Committees both the faculty of Health sciences and the Limpopo Department of Health. Additional information Thank you for your time and help to make this study possible. If you have any queries about your participation, please do not hesitate to contact me or my supervisors, Isabel Coetzee or Tanya Heyns, using the contact details below. Pitsi Motseo Work telephone: 015 287 5467 4  Student Nr: 4 3 7 3 6 7 3 4 Cell phone: 0827566280 Email address:[email protected] Supervisors Isabel Coetzee: 0832761422 Tanya Heyns: 0832873929 Confidentiality and anonymity Confidentiality and anonymity are guaranteed throughout this study. The researcher will not discuss your participation or your interview with any other employees out of the agreement. I would like to record the interview, but this would only be done with your consent. An independent facilitator will be involved in the process of Appreciative Inquiry. All information gathered in the interviews will be recorded and treated confidentially; your name will not be used. Consent to participate in this study I have read the above information leaflet and fully understand what is expected of me. Its content and meaning have been explained to me. I have been given opportunity to ask questions and relevant answers given. I voluntarily want to take part in this research study. ---------------------------------- ------------------------------ Participants’ signature Date Pitsi Motseo Researcher 5  Student Nr: 4 3 7 3 6 7 3 4 MOTSEO P.I. APPRECIATIVE INQUIRY INTERVIEW SCHEDULE 1. Theoretical aspect 1.1. Tell me a story about the best theoretical experience that you had as a student in the education and training for the Trauma Nursing programme ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ----------------------------------------------- 1.2. Elaborate on the aspects of theory that are valuable for the success in the programme ? ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ 1.3. Tell me about the challenges that you met in theoretical learning 6  Student Nr: 4 3 7 3 6 7 3 4 ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ 1.4. Imagine yourself as the facilitator in the programme; Which aspects in theory will you change, to refine the programme ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------- 1.5. How do you prefer the theory to be improved? ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ 7  Student Nr: 4 3 7 3 6 7 3 4 ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------- 2. Clinical Aspect 2.1. Share the most exciting peak experience that you had as a student in the clinical area during your training for the Trauma programme ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2.2. Which aspects do you value in the clinical practice of the programme? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2.3. Tell me about challenges experienced in the clinical area during training? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 8  Student Nr: 4 3 7 3 6 7 3 4 ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2.4. Which aspects in clinical training do you think needs to be improved or refined? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2.5. How do you prefer the clinical practice of the programme to be offered? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- Thank you for your participation .Your inputs are highly considered. MOTSEO P.I. (RESEARCHER) 9  Student Nr: 4 3 7 3 6 7 3 4 SECTION C DECLARATION CANDIDATE’S AGREEMENT TO COMPLY WITH THE ETHICAL PRINCIPLES SET OUT IN UNISA POLICY ON RESEARCH ETHICS I Pitsi Isabella Motseo (Name of student), student number: 43736734 have accessed, and have read, the Unisa Policy on Research at http://cm.unisa.ac.za/contents/departments/res_policies/docs/ResearchEthicsPolicy_apprvC ounc_21Sept07.pdf Yes:  No: I further declare that this form is a true and accurate reflection of the methodology I intend to apply, and that I have carefully contemplated possible ethical implications of the research methodology and domain specific and associated ethical issues and that I have reported on all of these. I shall carry out the study in strict accordance with the approved proposal and the ethics policy of UNISA. I shall maintain the confidentiality of all data collected from or about research participants, and maintain security procedures for the protection of privacy and anonymity. I shall record the way in which the ethical guidelines, as suggested in the proposal, has been implemented in my research. I shall work in close collaboration with my supervisor(s) and shall notify my supervisor(s) in writing immediately if any change to the study is proposed. I undertake to notify the Higher Degrees Committee of the Department of Health Studies (UNISA) in writing immediately if any adverse event occurs or when injury or harm is experienced by the participants attributable to their participation in the study. 29/11/2012 (Signature) (Date) 10  Student Nr: 4 3 7 3 6 7 3 4 SECTION D OBSERVATIONS BY THE HIGHER DEGREES COMMITTEE OF THE DEPARTMENT OF HEALTH STUDIES Is the proposal of an acceptable standard?  Yes  No  Minor adjustment need to be made and resubmitted  The proposal calls for a “redo” and resubmission  COMMENTS We have reviewed this completed Summary Sheet and are satisfied that it meets the methodological, technical and ethical standards as set in the Department of Health Studies and that it is in compliance with the UNISA policy on research ethics. Chairperson: Department of Signed: Health Studies’ Higher Degrees Committee Name: Date: Member of the Department of Signed: Health Studies’ Higher Degrees Committee Name: Date: Is the proposal of an acceptable standard?  Yes  No  Minor adjustment need to be made and resubmitted  The proposal calls for a “redo” and resubmission  COMMENTS 11  Student Nr: 4 3 7 3 6 7 3 4 We have reviewed this completed Summary Sheet and are satisfied that it meets the methodological, technical and ethical standards as set in the Department of Health Studies and that it is in compliance with the UNISA policy on research ethics. Chairperson: Department of Signed: Health Studies’ Higher Degrees Committee Name: Date: Member of the Department of Signed: Health Studies’ Higher Degrees Committee Name: Date: Is the proposal of an acceptable standard?  Yes  No  Minor adjustment need to be made and resubmitted  The proposal calls for a “redo” and resubmission  COMMENTS We have reviewed this completed Summary Sheet and are satisfied that it meets the methodological, technical and ethical standards as set in the Department of Health Studies and that it is in compliance with the UNISA policy on research ethics. Chairperson: Department of Signed: Health Studies’ Higher Degrees Committee Name: Date: Member of the Department of Signed: Health Studies’ Higher Degrees Committee Name: Date: 12  Student Nr: 4 3 7 3 6 7 3 4 Is the proposal of an acceptable standard? Yes  F inal No  Minor adjustment need to be made and resubmitted The proposal calls for a “redo” and resubmission   COMMENTS Are all reasonable guarantees and safeguards for the ethics of this study covered? Yes  No  COMMENTS We have reviewed this completed Summary Sheet and are satisfied that it meets the methodological, technical and ethical standards as set in the Department of Health Studies and that it is in compliance with the UNISA policy on research ethics. Chairperson: Department of Signed: Health Studies’ Higher Degrees Committee Name: Date: Member of the Department of Signed: Health Studies’ Higher Degrees Committee Name: Date: 13  ANNEXURE E:EXAMPLE OF TRANSCRIPTION Transcription group two Int : The first thing that I want us to talk about is your experiences in the training of emergency nursing with regard to both the theoretical and clinical aspects or let me just put it the way it is put here so that you have better understanding. It says tell me a story about the best theoretical experiences that you had as a student for in the education and training for trauma nursing. Any best experience, anything about the time you were doing the theory part of the course. Anything that comes to your mind which you liked, which you would like to share with anybody or to anybody. Normally what I would do if the situation is like this I know it is not always easy to crack or to break the silence. So what I would do is that I would just pose a question to you, remember we are discussing there are no right or wrong answer, then to help you pretend that I am not here please say anything positive that you remember about the content of the theory part of the course. I’ll go to h kitchen for 3 minutes whilst you are starting the discussion so that I don’t see who start first and who is reluctant. When I come back just ignore me. You are on your  own remember you don’t reach consensus. You are not discussing to give me answers you are just talking. Female: about the theory part isn’t it that we were given work to discuss and to present we didn’t have enough time to look at the other topics we only focused on our topics you forget about other people’s topics, and you find that when they are presenting there you don’t have knowledge of what they are saying because you were concentrating on your own topic which is too much, you find that you have a certain condition which is so long that you cannot finish it up and tackle another one Male: I found it very interesting and quite engaging in manner that the content or the curriculum itself is prepared to extensively expand our understanding on the content of theory that one should have mastered to qualify as trauma---in a way regardless of the manner in which it was taught I found it very well prepared and quite sufficient to enrich a person in order to be sufficient as a trauma nurse in the clinical practice. Male: another thing is the relevancy of the content. I think they are more specific they are not biased in terms of the requirement to qualify to train as a specialist I think their content is relevant and again theoretically the group discussion that we had I think it promotes the group cohesion I like the group cohesion Male: another thing on a positive note is that if you look at the theoretical part of a training as a practitioner is not very far from medicine, so we are able to interact more on a more serious level with the general practitioners because I found that during whatever round when doctors are discussing something you are not very far, you are up there with them they understanding that you got during the training Female: again it was a good course because when we were having like after group discussion when you go to present and whatever, the positive thing I liked with it it was our facilitators were having an insight so if you as a student you have a problem or you don’t reach (ke gore) meaning being knowledgeable in another way we were very satisfied because we knew that if we don’t understand something then we know that they got an insight and they got good knowledge and they can correct us and give us the light. Female: to add on that is that the work was too heavy for us because we concentrated on the topic you are given but to our surprise to our interest each and every topic that was given if the little information was given they are able to give more than we have. Male: the most interesting aspect is a---you know the condition we get at the basic level, when you are coming to this specialist level you find that we are dealing with terms and conditions but you find  that we are talking about the same conditions that we know but you find that there are a lot of things which we really didn’t take to consideration (female: we did that condition) and the very---am talking about the content and you think I did this but then you realise ( female: you were still very far) yea yea... Female: and when we do the preparation we were given the workbook to do the preparation, we do preparation thoroughly because our lectures are very much equipped with information, they just flow like a river so we have to seek more information on your preparation Female: and I would love to add that this course very much interesting and is also giving us more knowledge because before we came to this course I thought maybe people who are having trauma and general nursing is just the same but when I arrived here I realised that this course is more informative than general nursing because I found that it is very challenging, because when I came here I thought I am knowledgeable I’ve got information about anything looking at my experience but I have realised that no I was still lacking so many information. Some of the conditions I did not go in details I did not know how to do other conditions but after coming to this course I realised that I am not the same person as I was under general nursing. I realised that the information that is here is more important than  the information I was having before so I have gained more knowledge than before I came here at specialised nursing. Int: okay so those are the things that you liked best about the course isn’t it? (m….) and then eh…for this course to be a success or to continue keeping it the way it is what can you attribute it to? What aspects would you like them to improve or keep they way it is so that this course can continue to be a success? Male: I have a feeling that the exposure forms the most basic for succeeding in the course but I will agree that in the very exposure there should be a programme that assist those people who are coming for exposure. When I look back on the course itself I think it is very important that a person has an understanding of human anatomy and physiology, so in a way before they can enter in the programme it will be important that during the very same exposure somehow along the line they are exposed to various …which they think will imperatively like cardiovascular respiratory…those systems that are very critical in understanding the conditions and the treatment , during the exposure period they should be guided through them even write a specific test there if possible, some form of evaluation that will prepare them mentally before they can enter into the programme Int: sir you are too quiet (laughter) Female: I want to suggest something on exposure because this course has got a lot of work so maybe just to challenge us or to motivate us when we come for exposure and not to have that feeling of being workforces like we have workbooks, those workbooks if they can give us during exposure we will be able to be motivated because we will be knowing what is expected of us when we go to the class and those procedures like this they are basic procedures for trauma training so maybe if they can give us those workbooks so that when we start exposure we start with those procedures because some procedures we just see them there when we are doing exposure and after that you will never see them again. And they want those procedures to be signed so we are also loosing opportunity of signing the procedures that are in the workbooks because we don’t know what is expected of us as trauma trained so at the end you find that this thing I have seen them during exposure and nobody can sign for you because you were not having that workbook by that time and you didn’t know that this is falling under your curriculum of trauma training, if they can give us something so that we can keep on knowing what is expected of us so that Int: yea now you have already come into the challenges that you are experiencing, which is my next question. So are suggesting this has to come from you, what I have heard from you is that especially about the part on exposure are you saying it must also be curriculised? Structured in way that it needs to have its objectives, performance outcomes and also evaluation? (yes) so  are we adding or are we making it part? Isn’t it that now we have you’ve got your workbook already which comes post exposure, so are we saying there should be another workbook? Or another whatever that they may want to call it form of evaluation which help to be part of the curriculum whilst you are exposed to the environment is that what you are suggesting? All: yes Male: yes they can just invent a performance tool from there Int: as you were discussing I heard workforce exposure workforce will that now be able to demarcate that you are there for the purpose of exposure but as a normal working as you will be working in the ward.  Bokgoni consulting P O Box 423 BENDOR PARK 0713 Phone: 071 981 5632 Fax: 0866067109 E-mail: [email protected] TO WHOM IT MAY CONCERN Dear Sir/Madam RE: confirmation letter This letter confirms that the following services were rendered by Ms Langa R C of Bokgoni consulting to Ms Motseo P:  Facilitating/conducting Focus group discussions  Transcription of focus group I hope you find this to be in order Yours Sincerely Raisibe Cynthia Langa 018915632