Inclusive Skills and Entrepreneurship Development in Health Education for Sustainable Workforce in Delta State Primary Health Care Services
Chapter One
Research Aim
To identify the competencies that underpin the primary health care nurse’s role as a health educator in Nigeria.
Objectives:
- To identify the views of primary healthcare nurses as to the knowledge and skills required to engage in health education within a primary healthcare
- To determine whether consensus on the health education competencies required by nurses within a primary healthcare setting can be reached by engaging expert primary healthcare nurses in a formal consensus exercise (i.e. by using the Delphi technique).
- To engage service users, nurse managers and PHC nurses in a workshop that will present the competencies required, develop an action plan and make recommendations for piloting and evaluating during the post-doctoral period.
CHAPTER TWO
LITERATURE REVIEW
Concepts of health, health promotion and health education
Health can be conceptualised in a number of ways; Katherine Renpenning and Taylor (2011) state that health is not limited to one understanding. Various definitions and concepts support contrasting philosophies about health and underpin health promotion and health education interventions in different ways. There is no universally accepted definition or conceptualisation of health. The discussion here will consider a number of health concepts used within the literature and illuminate the concepts used to frame this research study.
It is stated by the “Oxford English Dictionary” (OED) (2014) that a person who is not infirm, or who does not have an injury, can be defined as healthy. The OED’s definition is interesting as post World War II, health concepts have emphasised the importance of holistic well being, as opposed to physical disease or infirmity. For example, it has been shown that health as a concept underpins the complete state of one’s health, which is a combination of mental, physical and social factors (WHO, 2011). The WHO concept of health implies that poor health relates not only to the presence of physical illness, as one’s entire existence is determined by it, but also hinges on a positive understanding of the social, physical and mental levels of a human being. Nevertheless, this specific definition has been scrutinised for its lack of recognition of emotional and spiritual factors, even though it is seen as positive (Ewles & Simnett, 2003). Further, as the definition provided by the WHO relies on a holistic understanding of a particular individual’s life, professionals in the health sector must analyse how each person interprets their own personal experience (Laverack, 2007). This is significant as many personal factors can be affected, such as status in society, self-confidence and the outside support they receive.
The WHO (2011) notion of health as a multi-dimensional concept incorporating emotional, social and other factors is also expressed within the Nigerian MOH (2012) definition of health, which states that ill health is more than the onset of illness in an individual, as health is actually the process of securing and preserving one’s mental, physical and psychological safety. This definition considers safety as an essential issue in the health for people within the community, as safe environments influence health in general. Moreover, MOH (2012) defines health as relating to the understanding, achievement and implementation of health concepts through their promotion, education, the prevention of disease and other preventative action. This definition is similar to the WHO’s 2011 definition, though there are differences in relation to the provision of psychologically safe environments for people.
It could be argued that the concepts of health given above, focus upon the subjective experiences of the individual and how they perceive health. In contrast Seedhouse (2016) suggests that health can also be conceptualised from a functional perspective and not necessarily just from an individualistic opinion base, as good health provides a person with the ability to perform and live their life (Seedhouse, 2016). In addition, Seedhouse suggests that an individual’s health is a platform for achievement; it is “equivalent to the set of conditions that enable a person to work to fulfil their realistic chosen and biological potentials” (Seedhouse, 2016, p.61).
It is also possible to comprehend health as not purely a concept, but also an acquired and developed human commodity, as it is shown that the function of positive health can be developed and even purchased through strategic construction in private care (Aggleton, 2011). More specifically, health is shown by Aggleton (2011) to have been developed into a commodity that can be ‘sold’, given medication purchases and the rise in health food shops, to the social conscience, ‘given & provided’ through medical intervention, or ‘lost’ through disease or injury. In this definition of health, it is clear that health functions together with modern consumerism.
In addition, definitions of health are built up from other umbrella terms, such as humanism and empowerment, which construct the concept of health in ways which go beyond mere medical definitions (Acton & Malathum, 2000). Health can be seen as highlighting how an individual is capable of coping in varied and changing circumstances, and so it focuses on a person’s ability to achieve their potential, which is underpinned by the concept of humanism (i.e., an emphasis on the value and agency of human beings). Following this, health can empower an individual to believe in his or her own self-actualisation (Acton & Malathum, 2000). Self-actualisation is defined as the “ongoing actualization of potentials, capacities and talents, as fulfilment of mission (or calling, fate, destiny, or vocation), as a fuller knowledge of, and acceptance of, the person’s own intrinsic nature” (Maslow, 2018, p.25). Therefore, health can be comprehended as a concept that creates the basis for future objectives and achievements (Seedhouse, 2001).
CHAPTER THREE
RESEARCH METHODOLOGY
Research design
The systematic search strategy and synthesis of the literature explored in Chapter Three indicates that few research studies have considered primary healthcare nurses’ views of health education and the strategies required to improve the health-education process within a PHC setting. This is a critical point, because if nurses have neither input nor ownership of health education competencies, and if they are not deemed applicable by nurses in practice, then it will be difficult to change or further develop practice, and thus enhance health education within primary healthcare nursing practice. Moreover, it is timely to elicit nurses’ views given that PHC roles are changing to accommodate shifting patterns of health within
Nigeria Also, the studies reviewed in Chapter Three evaluated specific, health-focused interventions, rather than identifying how health education could be enhanced to incorporate core knowledge, skills and attitudes for PHC nursing and health education. The research is context-specific to Nigeria, which has its own distinctive cultural and religious beliefs. Therefore, the Delphi technique is suitable for this research study as Delphi does not involve face-to-face contact with experts as found in other consensus methods, such as NGT; it was not necessary to meet together as a group. This is considered to be an advantage of Delphi, given the busy schedules of experts, and also ensures their anonymity and that of their responses; however, there is a chance of intimation and instruction in face-to-face meetings. Furthermore, due to the nature of social life in Nigeria, the participants may prefer to not meet with others, particularly if the meetings involve both men and women. Indeed, this has been identified as a challenge by the MOH (2009).
Data collection process
Creswell (2013) states that data collection is the process in which the researcher prepares and collects data from the field in an effort to ensure that sufficient data are available for evaluation. Further, the selection of data collection tools depends on whether this tool achieves the objectives of the research, helps the researcher to solve problems, and supports suspicions and hypotheses (Royse, 2008). Time and resource availability have to be considered in the selection of tools (Krishnaswamy et al., 2009). Therefore, in this research study, data collection was conducted using a Delphi questionnaire which aims to identify health education competencies for PHC nurses. The Delphi questionnaire was complemented by an interactive workshop involving primary Health Care workforce and service users, to determine what actions were required to pilot and evaluate the competencies within the primary health care environment, and to improve health education in the primary health care setting.
CHAPTER FOUR
DATA ANALYSIS AND RESULTS
The demographic characteristics of the PHC nurses
Table 6.1 shows that 17 of the respondent nurses were from Asaba, 36 from Umuaji, while the remaining seven were from Umuonaje. Considering gender, there were five males from Asaba, four from Umuaji and one from Umuonaje. Bachelor degree (BSN) level education had been achieved by six respondents from Asaba, ten from Umuaji, and four from Umuonaje. The remaining 40 were diploma certificate holders who matched the inclusion criteria, (a. had a bachelor’s degree in nursing and at least one year of nursing experience, or a diploma in nursing with at least four years of nursing experience, b. ability to speak Igbo and/or English). The average (mean) age of the total sample was 33 years, with a standard deviation of 7.2 years. The average experience of all experts was 10.8 years.
CHAPTER FIVE
CONCLUSION AND RECOMMENDATION
Conclusion
This study has identified that PHC nurses need to learn different skills within nurse education that will lead to an improved health-education process. It has been noted that PHC nurses require continuing education and training courses, as stated in the previous literature (Baxter et al., 2013; Mersal & Keshk, 2012; Perry et al., 2008). These courses should include: the skills to provide health education, the key public health challenges and topics that nurses have to be aware of, and to act upon within health education practice, and the different methods of interaction with people, for example discussion and reflection methods that increase the interaction between people. Expert and qualified professionals can provide these courses, as specialised post qualifying courses for PHC nurses, in order to keep health education as an important aspect in the PHCCs. This is because PHCCs can be considered as the first contact for patients, and people in the community prior to referral to the secondary and tertiary levels of health care. Additionally, these courses can be provided as well to all registered nurses as Whitehead (2001) and Shaw (2019) identified that health education is a part of nursing performance despite the settings for nursing work.
Therefore, it seems crucial for stakeholders, nurses and nurse managers, to consider the workplace conditions as well as barriers that hinder health education in practice. The barriers can be from patients, staff or the organisation itself. Abdulhadi et al. (2013) identified some of the barriers, such as workload, poor patient commitment, and communication problems. The details of health education barriers have been explained in Chapter Three. For example, the health education process will be valuable and achieve its objectives, if staff demonstrate their interest in this task. Also, when the environment is suitable, such as a private room and availability of educational materials health education may achieve its objectives. Such enabling factors are potentially rewarding for staff, enhancing their effectives and encouraging them to educate patients.
Conducting a workshop or any activity following the research has the potential to encourage workshop participants to apply the ideas generated into practice. This study has found that using technology by social media, such as Twitter or WhatsApp, to deliver health education has the potential to be effective and flexible for the community. Service users within the interactive workshop advocated the use of technologies, and this is an important finding for the study. An implication of this is the possibility to design useable apps about specific health problems and send messages of health education through this application. For example in Delta state where, there are high rates of obesity as explained before, it will be useful to design apps with the cooperation from IT researchers and PHC staff. Further, other health problems such as, diabetes, hypertension, and problems during pregnancy have to be considered as well. In the UK for example, Light and Ormandy (2011) organised a digital campaign in cooperation with the Lesbian and Gay Foundation in order to engage women in same sex relationships to undertake cervical screening. This campaign used a mobile phone app which sent promotional videos and an evaluation mechanism to improve its performance.
The involvement of the service users with a combination of PHC nurses in the workshop was effective and successful as they added to the research results. Therefore, the interactive workshop enabled achievement of the research aim and objectives. Overall, the workshop strengths included the skills of the researcher, in term of guidance and facilitation of the discussion and interaction between the groups. This is an important development as in Nigeria service user involvement does not normally take place.
The results from this study support the new Nigerian Strategic Plan for Primary Healthcare Nursing in Nigeria The Plan confirms staff competence in all nursing-care practice, including health education (MOH, 2012). Therefore, these results represent the first step towards developing a set of nationally agreed health education competencies for PHC nurses. These competencies were refined and checked with nurses’ managers, staff and service users by conducting a workshop. So, the next step is to develop an action plan and recommendations for piloting these competencies in the post-doctoral period. This can be achieved with the PHC nurses and nurses’ managers. Therefore, there will be a post qualifying educational course for PHC nurses, which will teach the health education competencies.
Recommendations from this research
This research has explored 45 health education competencies for PHC nurses in Nigeria by including expert participants in three rounds of Delphi. The recommendations from this research will be divided in different aspects, in the following section.
Recommendations for policy makers
- In order to keep up-to-date with wider changes along with health concerns, primary healthcare policies have to be updated regularly and checked frequently in order to ascertain the importance of health education within the PHC setting. This could draw upon the MOH strategies that are regularly However, more specific focus and attention on health education practice are needed. This can be achieved by presentations as to how health education improves health outcomes and decreases complications for diseases when they have occurred.
- It would be interesting to assess the work performance of PHC nurses and ensure staff development through providing training courses regarding boosting the performance of health education within the PHC setting. This was a main outcome from the workshop. These courses have to be evaluated and updated frequently in order to accomplish their
- Greater efforts are needed to ensure the practice of health education within the PHC setting by frequently assessing and evaluating the practice of health education by PHC nurses as this was an outcome from the This can be achieved by comparing the health education practice in Nigeria with other countries such as the UK, where practice nurses play an important role in health education via education classes and consultation clinics. It is further recommended to develop a ‘peer evaluation’ that PHC nurses evaluate the performance of health education for their colleagues.
- Considerably more attention and care will required to determine the suitable environmental factors and managerial support which will enhance the process of health education, including building of the PHCCs and educational materials, as discussed by Bergh et (2012) that the practice of PHC nurses as health educators is influenced by organizational and managerial support.
Recommendations for nurses mangers
- It is suggested that providing training courses for the staff will be effective to improve their skills and knowledge of health education, as Mersal and Keshk (2012) found that intervention programmes for nurses in MCH centres enhanced the performance and knowledge for them regarding health This can be done through developing courses run by expert nurses and nurse mangers who participated in this study, and the course content will be based upon the research findings. Therefore, health education performance by PHC nurses will enhanced.
- It is vital to indicate the barriers to providing health education and try to solve these issues. Douglas et al. (2006) listed some barriers that impede health education processes within the PHC setting such as: lack of extra payment and rewards, lack of time, and insufficient educational The nurse managers have to overcome these struggles by different means: reward the staff (increase payment), provide educational materials, and improve the environment by providing private room for health education sessions.
- It is essential to maintain good communication and relationships with the health professionals from a different faculty to promote Abdulhadi et al. (2013) mentioned the importance of teamwork when providing health education as this can be an obstacle which has to be resolved. It is important to schedule regular meetings with all health professionals in the PHCCs in order to exchange ideas and share experiences regarding health education. This meeting can take place in the PHCC itself or on-line via skype.
- Rewards and incentives should be provided for PHC nurses who have successfully incorporated health education into their role, through regular assessment and supervision of staff. Rewarding could include the provision of study scholarships, conference attendance, or increased
- It has been noted to provide an appropriate environment to conduct health education sessions, as this has an influence upon patient nurse
Recommendations for PHC nurses
- The PHC nurses need to consider providing health education to the patients visiting PHC centres, as one of their roles. This is clear in the Nigerian strategic plan for PHC nursing, which recommends competence for all nursing activities within the PHC setting including health education. This can be achieved by ensuring health education practice is included in the job descriptions of PHC nurses in Nigeria
- The PHC nurses have to enrol in courses that improve their skills and enhance competence in health These courses concerned with the practice of health education may be within the gulf countries or globally. In future, after this study is published, there will be a post-qualifying course for PHC nurses that are concerned with health education.
- The PHC nurses have to be aware about the cultural differences between the patients, as Nigeria is a multi-cultural country. This is a critical issue as S. A. is a multicultural country, which has nine million individuals from overseas (World Population Review, 2016). The PHC nurses have to respect all cultures and deal with the patients as humans without discrimination, keeping in mind the individual’s
- The PHC nurses have to listen and respond carefully to patients’ needs, to be aware of verbal and nonverbal communication, as Abdulhadi et al. (2007) confirmed the importance of communication during health education through eye contact, attention, and encouraging patients to ask questions.
Recommendations for service users
- It is advised to support service user involvement in research Williamson et al. (2007) pointed out the importance of involving service users within the research process starting from proposal of the topics and ending with writing reports about the findings. Service user involvement is recommended for future research in order to have a positive influence and achieve the research aims.
- It is meaningful to have the contributions of service users with groups of health
- It is suggested to keep the outcomes from the service users in hand when developing health policies as well as curriculum planning in the nursing colleges, in keeping with the experience of (NICE) (2013) when involving service users and the public in NICE
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