Evidence Based Health Policy,

Investigation of Challenges Ahead of in-service Training for Nurses in Educational Hospitals of Isfahan City in 2016: A Qualitative Study
 
Ahmadreza Reisi ¹, Marziyeh Javadi ², Reza Mohamadnezhad ^*3
 
1 Health Economics Management Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Health Economics Management Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Student Reserch Committee, Isfahan University of Medical Sciences, Isfahan, Iran
 

Citation
This paper should be cited as: Reisi A, Javadi M, Mohamadnezhad R. Investigation of challenges ahead of in-service training for nurses in educational hospitals of Isfahan City in 2016: a qualitative study. Evidence Based Health Policy, Management & Economics. 2017; 1(3): 142-50.
 

 
Introduction

raining people on the occupation they are active in has always been of interest to human. In today’s complex and dynamic world, learning plays a significant role. Education is the basis of all learnings and a key factor in improving human workforce (1). Researchers and scientists believe that employees are the most important competitive advantage in organizations and human capital meets all the strategic needs of an organization (2). Today, employees have a major contribution in the progressive transformation of administrative and employment systems and presentation of optimal services (3).  Thus, it can be stated that a fundamental measure that can be taken to enhance organizational efficiency is employing human resources capital through training and improvement. Training human resources is essential for enhancing the productivity and progression of the organization (4). As the life and survival of organizations are largely dependent on the knowledge and skills of their employees, skilled and trained people will have a more effective role in the efficiency and productivity of the organization (5). By investing in developing human resources, knowledge, skill, potential and attitude, organizations can promote their employees to handle global competition (6).
One of the most important service organizations undertaking healthcare and protecting public health capital in the society are hospitals, which with their professional bureaucratic structure have employed a set of skilled, specialist, and expert workforces to provide specialized clinical and nursing services (4).
As with other organizations, such organizations have recognized the importance of training their employees and health care providers to reduce loss of human resources and promote professional knowledge and connect with environmental advances to benefit from developing knowledge and novel medical techniques. They have also established organizational training systems to empower their human resources. However, the issue that should be considered here is how training units and departments for development of human resources will operate to improve the effectiveness and performance of the employees in this organization. This is because timely identification of training needs and holding associated training courses meet knowledge and skill needs, thereby satisfying patients and clients, which in turn guarantees organizational sustainability (7). A major part of professional employees in hospitals consists of nurses. As most scholars believe that formal academic education as well as intensive and limited pre-service trainings do not prepare nurses for effective fulfillment of their tasks for practical nursing cares to an acceptable level (8), thus the necessity of needs assessment and planning for preparing, developing, and implementing training courses related to individual, occupational, and organizational needs of nurses as an instrument for obtaining information and responding to rapid changes in the health system and promoting professional knowledge and skills is felt more than ever (4). For advancement and coordination of nursing profession with the advances in technology, in-service training is introduced as a valuable and economical method (9). Continual training of the medical community is considered a novel strategy for preserving and promoting the knowledge of medical community (10).  In-service training can make the person to be familiar with their current needs and provide them an opportunity to adapt to the conditions associated with their duties (11). Considering the rapid advancement of technology and knowledge as well as the very close relationship between nurses and patients and other medical team and the society, training them seems to be essential more than ever (12). In other words, owing to the essential role of nurses and scientific advances regarding nursing cares, presentation of nursing services with a desirable and excellent quality would not be possible without in-service training, study, and familiarity with novel methods, as their knowledge and insights to problems are factors influencing the quality of nursing cares (13). Providing and designing continual training programs, in line with the training needs of target groups is of high priority in implementation of plans, which has always been emphasized by the medical community (14). Neglecting individual needs, organizational requirements, and patients as consumers are factors that can cause reduced effectiveness of training courses (15). The rubrics of continual training programs should be reviewed regularly and in line with the needs of learners. Teaching method should be mainly in the form of performing or observing a practical job, and novel methods should be employed in implementation of programs (16). In a review study, the major dissatisfaction of the medical community was lack of congruence between occupational needs of people and clinical problems of physicians with the topics cited in continual training programs (17). Generally, there are no accurate statistics available in Iran and overseas regarding the extent of participation of nurses in in-service training programs. The factor that has been proven practically regarding in-service training is its effect on the performance of nurses (18).
Based on the above mentioned points, the necessity of in-service training is felt and it elucidates the need for conducting research on influential factors in motivating nurses to participate in in-service programs. The current conditions prompted the researcher to conduct a study on challenges ahead of in-service training in educational hospitals of Isfahan city to identify influential educational barriers and present solutions to solve them.
Materials and Methods
This research was of qualitative study type, performed through a phenomenological approach. The data collection method was structured interviews. The studied population consisted of three educational supervisors, four head-nurses in clinical sections, and three educational liaisons
of specialized and sub-specialized hospitals of Azzahra- Amin Specialized Hospital, and Ayatollah Kashani Specialized Hospital in Isfahan, which had a background of more than 15 years, with this very long background being the inclusion criterion of the subjects. The sampling was done by snowball method, where the person who was interviewed introduced the next person. The duration of each interview was calculated to be 35 minutes on the average. Validity of the text and questions of the interview was measured based on the comments of educational experts and scholars, and to measure its reliability, several mock interviews were done with these people.
Accordingly, 10 in-person interviews were performed and the data were analyzed after recording and implementation. Data analysis was done by content analysis approach. Content analysis is a type of subject analysis, which is used for investigating the clear content of messages in a text. In this regard, the data are categorized based on topics and read in-depth several times by the researcher, in order for him to gain a full mastery over the topics. Next, the text of interviews is broken down in the form of similar sentences and paragraphs and coded as similar codes. Then the separated topics are specified as primary codes and titles, while the content related to each code is regarded as secondary codes. In addition, the declaration of Helsinki was considered for ethical issues. 
 
Results
In this research, the five primary codes were: support of managers, needs assessment, time period, funding, and content of in-service training program. Further, thirteen secondary codes were also obtained.

 
Table 1. The primary and secondary codes extracted from the text of interviews

Primary Code 1 – Financial and spiritual support of managers from in-service training programs Secondary codes

Lack of practical support by hospital managers and policies from in-service training programs, was reflected in the speech of nurses as follows:
Participant 2 stated that “personal must use their leave hours for training, which has no effect on their salary. It is not considered as overtime either. There is no motivation to participate in these classes”.
Participant 4 said that “Hospital managers care for these courses and support them, but the support of interest is financial and practical support, which occurs less frequently”.
Participant 4 stated that “well, if we  do not need financial support, and it is mainly providing classes as well as learning-aid tools and reception, they support more, otherwise financial support is not very bold and they support mainly in the form of center equipment”.

Participant 8 stated that “the support they provide is mainly verbal and that which is of special interest to us is a true financial support. It supports the personnel to participate in these classes, not that the person participates in the class with no extra salary or perk with no motivation”.
Participant 5 stated that “even sometimes we have problems with our class reception. Even when we requested, they said that we cannot afford to buy even one simple pen. Yet, it depends on the situation. For example, sometimes the personnel remuneration is delayed and the manager is preoccupied with solving such problems, and not the training. We even had the problem of considering these training hours as shift for the personnel, but the university did not accept that and said “every hospital can treat out of its taste”.
Participant 9 stated that “they support verbally, but in practice there is no support required for the personnel, so that they can participate in classes willingly”.
Participant 10 stated that “it depends on the sources! If sources mean reception and a couple of papers and pens, it is true, but supplying the sources of courses is beyond these things and involves a suitable site for inviting experienced and good professors, etc.”
Participant 6 stated that “as I mentioned, they support us mainly in the form of center facilities, and if professors are to be invited from Tehran or we want to go for training somewhere, they do not support that much. However, we think that there is budget for training and if this budget was provided for the training supervisors themselves to plan for it, it would be better”.

Participant 8 stated that “the organization itself has no such  policy for promotion based on training, though previously, if a person had 700 hours of training in their background and was involved in a research plan, they would give them an equivalent, e.g. from Bachelor’s to Master’s, but it is no longer applicable”.
Participant 2 stated that “if people are able to have 1600 hours of education across four years as training classes, I mean continual training courses not any kind of training, they give them equivalent. However, there are few people who can acquire such hours and unfortunately if you have nepotistic relations, you can get your job done”.
Participant 4 stated that “well, see we have to participate in some of these courses and when training hours go beyond 700 hours, they calculate it in evaluations”.
Participant 5 stated that “in the past, one or two programs were held, and they gave us equivalent based on their training hours, but unfortunately this plan has been stopped”.
The second primary code: Challenges of needs assessment regarding in-service training courses.
Secondary codes

Participant 4 stated that “look, we always perform needs assessment, but as all our jobs are in haste, the vice-chancellor of treatment gave four days to perform the training needs assessment and send to them the relevant forms. For this, the deputy collects all needs assessment from all centers and sends a training and design package to all healthcare centers, which is common for all (though for single specialties it plans separately, e.g. for burning accidents). We have to hold the training course within this framework and if we want to hold a new training course regarding a new system, we are no longer able to”.
Participant 1 stated that “we have two types of training: one is intra-sectoral and the other is extra-sectoral. In the former, we carryout needs assessment and hold test every six months, which is useful, but in extra-sectoral trainings, as the number of forces does not grow, it is not possible to perform a reasonable needs assessment and further, all needs of the personnel are not taken into consideration and mostly the compulsion by the deputy is applied, since they should be responsive to the university at the end of the year”.
Participant 3 stated that “we cannot say that it is completely so, as nurses have different needs,  and all of these training needs are not met in these courses”.
Participant 5 stated that “typically, we perform needs assessment, but the challenge we have in the deputy is that we want them to let us be the planner, but unfortunately the deputy does not accept as it faces more workload. They then send us a package and say that it is based on the needs of all centers”.

Participant 6 stated that “yes, we perform training needs assessment for the personnel, but you  that the needs of different sectors are different and we cannot hold classes for all of them. Even, some classes in which they participate are not useful to them. We then have to tell each sector to hold intra-sectoral classes, and whether they hold the classes in this way or not depends on them”.
Participant 8 stated that “needs assessment is performed, but it does not have a significant effect on their training, as mostly the plan of the deputy is implemented, while the personnel opinions are not applied that much”.
Participant 10 stated that “see, every nurse who has a need introduces it into HIS system and the hospital’s educational supervisor collects this information and holds classes based on it. However, all needs of nurses are not met. We perform needs analysis for our personnel, but as I mentioned, it is not very helpful”.

Participant 2 stated that “yes, we take the society’s need into account in these courses, but we do not achieve our desired outcome, and the system is planned in a way that it merely does something, no matter whether it is rewarding or not”.
Participant 9 stated that “the trainings are more or less up to date, but as the plan comes from the deputy and perhaps out equipment differs from other centers’, we have to make some changes in it ourselves”.
The third primary code – Time range challenges in in-service training

Participant 2 stated that “no special surveying is done, we simply announce the plan and the personnel have either free time or they should take some hours off and participate in the class”.
Participant 4 stated that “there is no special surveying, the super training itself plans and the personnel give their time based on that planning”.
Participant 10 stated that “there is usually no special needs assessment and mostly the personnel themselves should adapt and see if they have free time, and choose that time to participate in the classes”.

Participant 6 stated that “if the deputy compels us to hold classes at special hours, it definitely develops disorder in the job of our departments”.
The fourth primary code – Challenges of funding in-service training
Secondary codes

Participant 4 stated that “these courses are funded by the current budget of the hospital and there is no special bill for it”.
Participant 9 stated that “no special source has been predicted, we only give our request, the management then approves and if it had a warehouse, they give us, otherwise they buy. We even told them to allocate a certain sum of money to educational supervisor, so that he or she can have a special planning method. However, they said no and request whatever you like”.
Participant 8 stated that “it has no special budget; it is funded by the hospital budget”.
Participant 3 stated that “we have no special source for holding our training courses”.
(I do not think it has a special financial source, it is mostly the hospital budget).
 The fifth primary code –The challenges of the training course content.
Secondary codes

Participant 2 stated that “it is also in the hands of the deputy (we have a terrible situation, please help us)!”

Participant 6 stated that “some of them have the expertise and some do not. As we cannot ask our physicians to come in the evening, we have to employ our head nurses who have skill”.

Participant 3 stated that “absolutely not. As these courses are held as teacher-student and the learners have no participation, it is extremely boring and they come only to obtain more scores.  I would even like them to say that training has no score, so that no one would show up. The only reason for participation is the very score, which affects their employment rights and salary”.
Participant 1 stated that “no, as these trainings have absolutely no financial gain for the personnel and participation in the courses has been compulsory, this even wastes the off hours of the personnel” .
Participant 2 stated that “no, as people participate in the classes out of a compulsion and it is not regarded as working hours for them”.
Participant 9 stated that “see, saying that sense of loyalty develops with training is not 100% true, as sometimes our personnel do not have enough time and they have to use their off hours which is a bit annoying to them”.
Participant 7 stated that “to be honest, the only motivation of the colleagues is gaining training score and there is no trace of development of sense of loyalty”.

Participant 5 stated that “the test is held, but for it, the personnel enters the system through automation and determine the effectiveness by responding to some questions, which have no value and validity”.
Participant 10 stated that “pre- and post-tests are held, but they have no special value, as they take the test in place of each other or they sit for the test together, which is of little value”.
Discussion
In-service training is one of the most effective training methods in improving nurses for professional development and enhancing their qualifications. In this research, five primary codes were examined regarding in-service training in educational hospitals of Isfahan City. In the first primary code, which took support of managers into account, the main complaint of the hospital staff was lack of support of managers from calculation of work shift in exchange for participation in training courses, which developed into a great deal of dissatisfaction. In the second primary code, which was mentioned regarding needs assessment, lack of complete attention to organizational needs and the care and treatment staff of the hospital by the vice-chancellor of treatment was the main complaint, as it challenged the hospital independence in this regard. The third code was time range, where fortunately no special problem was found, except for cases where the care staff had to adapt their work schedule with training programs. The fourth primary code was funding for holding courses, where unfortunately numerous problems were observed in this regard, as the hospital’s training planners were unable to hold quality training courses and prepare the necessities due to lack of special budget for training. In the fifth primary code, the course contents were examined, where again unfortunately this part had also numerous problems including not employing experienced professors for all courses and improper measurement of effectiveness of these courses. However, it should be noted that training courses can bring about improvement and progress of the human resources if they are presented properly, methodically, and based on the staff needs (19). At any occupational level they stand, nursing managers are responsible for developing and improving nurses who stand in the lower levels of career (20, 21). Asthe results of Gholamnezhad et al.(4), indicated that  not receiving rewards and enough perks on the part of nurses causes job dissatisfaction and work stress in them, where as in this study, the nurses considered lack of support of managers for offering rewards in exchange for training hours as one of the main challenges of in-service training. In the study by Zaeimhagh (22) , it was also mentioned that if nurses do not have promotion based on their job background, they face occupational stress, where as in this study,  the nurses considered lack of support of managers from nurses regarding promotion based on training hours as one of the main challenges of in-service training.
Conclusion
The findings of this research establish that most educational problems arise from lack of discretion for planning training courses by the hospital itself, as the needs of one center is different from the needs of others. In the case of applying a single plan, problems such as these training challenges will arise. The results of this research suggest that in order to prevent training problems, three major pillars of decision-making, i.e. the university, vice-chancellor of treatment, and hospital should make a single decision by holding joint meetings, such that the needs of all sides are met in a way that they have no mismatch with the plans of other organs.

Conflicts of interest
The authors mentioned no conflict of interests for this research.
 
Acknowledgement
All experts who participated in this research are highly appreciated.
 
Authors' contributions
Javadi M designed research; Mohamadnezhad R conducted research; Reisi A analyzed data; and Mohamadnezhad R wrote the paper. Mohamadnezhad R had primary responsibility for final content. All authors read and approved the final manuscript.
 

1)  Gholam Nejad H, Nikpeyma N. Occupational stressors in nursing. Iran Occupational Health Journal. 2009; 6(1): 22-7.
2) Cabrera  E.F, Cabrera A. Strategic human resource evaluation.  Human Resource Planning. 2003; 26(1): 41-50.
3) Haji-Aghajani S. Study on attitude in personnel of Semnan University of Medical Sciences about
annual performance evaluation. Teb va Tazkieh 2005; 14: 37-43. [In Persian]