Do Thi Ha* and Khanitta Nuntaboot
Faculty of Nursing, Khon Kaen University, Vietnam
Received date: September 08, 2016; Accepted date: October 24, 2016; Published date: October 30, 2016
Citation: Ha DT, Nuntaboot K (2016) How Nurses in Hospital in Vietnam Learn to Improve their Own Nursing Competency: An Ethnographic Study. J Nurs Care 5:368. doi:10.4172/2167-1168.1000368
Copyright: © 2016 Ha DT, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
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Background: Competency affects several aspects of the quality of nursing care and has a significant contribution to the patient outcomes. There exists little up to date information concerning nursing profession as well as how nurses employing in clinical settings in Vietnam learn to improve their own competencies. Objectives: To investigate the ways Vietnamese nurses practicing in clinical settings have learned to improve their own competencies. Methods: A qualitative study, ethnographic method, comprised of the participant-observation, in-depth interview, and focus group discussion with multidisciplinary groups of nurses employing in Cho Ray Hospital, Vietnam, managers/administrators, nurse teachers, other health care personnel which derived from purposeful sampling technique. Content analysis was used to analyze the data. Findings: The two ways of learning in order to develop competencies among nurses were identified by the participants through the data collection in this study, including formal and informal learning. Nurses have received their formal training in nursing education programs in nursing schools after graduation to upgrade their nursing professional level was identified as formal learning. However, in the situation of nursing education in Vietnam, there has been rare of formal nursing education programs in bachelor level and higher, informal learning included continuing nursing education, learning from working experience, learning from daily reflective process, and coaching and mentoring was a vital learning strategy for nurses to apply in order to enhance their competencies. Conclusion: The findings from this study provide valuable information and understanding of the ways Vietnamese nurses working in hospital context have learned to improve individual competencies. It would assist to establish an effectively and appropriately strategy in an effort of enhancing nursing competency among nurses in Vietnam.
Competency development; In-depth interview; Nurses; Vietnam
Across a broad field of care, health issues, health care needs as well as the current health care system and nursing workforce issues stipulate that nurses be capable of performing optimally and assuming mounting responsibilities. Throughout the course of providing care to patients, nurses must be proficient in adjusting, applying critical thinking and problem-solving skills and corresponding efficiently with multidisciplinary team members. For nurses to be able to meet the complex blend of nursing practice, clinical nurses need to further acquire various knowledge and skills, beyond the focus of basic knowledge and technical foundation skills that they have been educated and trained on during their nursing education courses, in order to become competent individuals .
According to literature review, previous studies have identified that nurses practicing in clinical settings apply numerous of strategies in order to improve their individual competencies [2,3]. Nurses use both formal and informal learning strategies to enhance their capacities .
Merriam and colleagues mentioned that formal learning takes place in educational institutions, leading to degrees or credits . This is relative to nurses receiving their formal training in nursing education programs. Marsick and Watkins suggested that formal learning is typically institutionally sponsored, classroom-based, and highly structured .
On the other hand, informal learning refers to the “experiences of everyday living from which we learn something” . Marsick and Watkins proposed that informal learning may occur in institutions, but is not typically classroom-based or highly structured, and control of the learning rests primarily in the hands of the learner. It is typically experiential and non-institutionally based, rather a planned learning opportunity . In a qualitative research, Sharoff interviewed 10 nurses employing in hospital to explore how experienced certified holistic nurses learned to become competent holistic nurse practitioners. The findings showed that the nurses used informal learning strategies including learning from experience, from selfreflection, mentoring, or learning from colleagues and others to help them achieve expectation competency .
In Vietnam, nurses encompass the largest group of healthcare personnel employed in the health sector . Undoubtedly, they exhibit a vital role in providing health care services to clients. Unfortunately, a large number of Vietnamese nurses possess just a secondary level in nursing education accounting for around 70%, so they work in hospitals and clinical setting as workers and focus on medical techniques [5,6]. In addition, the traditional nursing in Vietnam is very technical and task-oriented; extremely focused on completion of a goal. The health care tasks of both physicians and nurses in clinical settings are focused entirely on the disease process . Meanwhile, holistic nursing, applying in the national level, affords nurses the opportunities go to beyond this focus by reconnecting to self and others on a deeper level . These require nurses in Vietnam need to develop their individual competencies in order to meet the requirements.
Over the years, in order to stay with the changing pattern of diseases and increasing of health care needs in Vietnam, the Vietnamese health care sector has strengthened and applied model equipment, and high technologies in terms of diagnosis, treatment and caring for patients. Indeed, the health care service has achieved certain successfulness; nonetheless, it has been faced with many challenges . These require health care professionals including nurses in Vietnam to be well prepared and competent so as to serve the health care needs and demands of population.
At present, there are three main educational preparations for nurses in Vietnam, including secondary nursing education (two years), college nursing education (three years), and baccalaureate nursing education (four years), in which baccalaureate degree still remains limited. Recently introduced were post-graduation educations in nursing such as specialty level I and master degrees; however, still rarely . There exists little up to date information concerning nursing competencies in Vietnam as well as how nurses acquire the needed knowledge, skills and attitudes in order to foster their proficiencies.
The purpose of this study is to provide an understanding of strategies that nurses practicing in clinical settings in Vietnam have applied in order to develop their individual competencies. Understanding how nurses develop their competencies in particular cultural and social contexts in Vietnam would indeed benefit development and innovating strategies to improve nurse competencies in Vietnam; thereby having a positive effect in enhancing quality of nursing care.
Design: A qualitative research with the ethnographic approach was selected in this study by allowing the voice and experience of Vietnamese nurses practicing in clinical settings to be heard, thusly providing opportunity to actually truly discover how nurses develop their own competencies. Qualitative research methods have become increasingly important as models of inquiry among various disciplines such as sociology, psychology, education and nursing . The purpose of this approach is not to test or verify researcher hypotheses on a given topic; rather, it is to obtain a deep understanding of participants’ perception and experience and the meaning they take from that experience. Qualitative research is used for the understanding of what lies behind the phenomena as well as providing intricate details of the phenomena that are difficult to convey quantitatively . The purpose of this study was to obtain a succinct understanding of the ways that Vietnamese nurses practicing in clinical settings have learned to improve their own competencies. By applying the qualitative approach, the researcher believed that rich and accurate information with regards the research topic would arise.
Setting and sample: Derived from purposive sampling, there were twenty-four participants who participated in this study. Of these participants, there were sixteen nurses as the key informants who were working in the clinical units in the Hospital with at least two years of experience in nursing profession. Other participants included nurse managers, administrators, teachers, and medical doctors. The study was conducted at Cho Ray Hospital, one of the two biggest national general hospitals in Vietnam under the Ministry of Health of Vietnam which is located in District 5 of Ho Chi Minh City.
Ethical considerations: Ethical approval was both obtained from the Khon Kaen University Ethics Committee in Human Research and the Research Division of Cho Ray Hospital. An information sheet, invitation letter, and consent form were sent to all participants directly with a clearly explanation about purpose, methods, procedures, potential risks and benefits of the study. Participation was voluntary and written informed consent was obtained or verbally consents. Participants were free to withdraw from the study at any time.
Data collection: Data had been collected during seven months starting in 2015. After obtaining permission for collecting data, the researcher entered the sites for establishing a rapport and developing a trusting relationship with nurses and other healthcare personnel in the setting. The data were gathered through participant-observations, indepth interviews and focus group discussions. The researcher accompanied the nurse participants during their working shifts in the hospital as well as some other relevant activities outside the field to observe and learn how they acquire knowledge and skills in order to enhance their proficiencies.
There were twenty-two individual in-depth interviews and three focus group discussions were produced. Each interview participants in this study gave one to two times of interview, lasting from 30 to 45 min for this session. The interviews took place at a venue convenient to the participants in an effort of increasing the convenience and comfort to the participants as well as the successfulness of the interview. Each focus group discussion was composed of four to six members. Many of these participants had been involved in the in-depth interview situation before. The researcher acted as moderator to direct the participants regarding the topic to be discussed and to ensure that all voices of the participants to be heard. All the interviews were digitally recorded, with the participants’ permission, and supplemented with detailed take notes. The research participants were asked to describe the ways nurses develop their competencies.
Data analysis: Content analysis was applied to analyze the data. The analysis and synthesis process were immediately conducted at the completion of each participant-observation, individual interview and focus group discussion session. For The data gathered from in-depth interview and focus group discussion, the tape recorders were heard and transcribed carefully. All of the transcriptions were then read several times and the key words or terms throughout the transcription were highlighted and noted. The coding then was made. The final emerging themes and categories were established.
The research participants indicated using formal and/or informal learning strategies to help nurses to improve competencies. The strategies of development competencies among nurses are presented in Figure 1.
The nurse participants described that they have used a variety of learning situations to foster their learning process. Many of them have chosen upgrading nursing level by attending higher nursing education programs in nursing schools, identified as formal learning. The programs included secondary level; associate degree; bachelor degree both full time and part-time education; specialty level I in nursing, master and doctoral degree (planning in the future).
“I attended the bachelor of nursing to improve my competence. Before, when studied in secondary level, I had just been learned about nursing technical skills. I could not understand the mechanisms. However, when I studied bachelor degree I understood more about this. When we understand the mechanisms we will know the way to care for clients better”. (ID 03)
Meanwhile, the nurse participant (ID 09) expressed that besides gaining nursing knowledge from his formal learning program, his critical thinking, emotional control, or his compassion manner have been also improved and changed towards positively:
“I have learned from this course (bachelor of nursing) a lot. Before attending this course, I sometimes have trouble in controlling my emotion. However, by this course, I have changed my mind and my emotion control toward positively. I understand the patients more and especially improve my communication skills”.
In the same line, a female nurse expressed how positively shift in her life through her formal learning course (ID 12):
“I felt so happy during my course (bachelor nursing course)…There I had many new friends, much better than when I just worked in my institution. Before joining this class, I rarely smile…You see, now, I smile very often. It’s so nice. My competency has been also improved significantly…”
“We encouraged and sent them (the primary or secondary nurses) to nursing school to upgrade their nursing levels to be higher…that was an important way to help them to develop their capacities…Just secondary level or less…could not care for patients effectively”. (Mentioned the nurse manager ID 22)
“I wish I have opportunity to upgrade my nursing level from secondary to bachelor and higher. Now, I am in secondary level… insufficient knowledge and skills to care of patients…”. (Stated the secondary nurse ID 14)
Although there has been limited of nursing education programs in bachelor level and higher in the situation of nursing education in Vietnam currently which results nurses lacking of opportunities to upgrade their nursing certificates as well as competencies, most participants in this study concerned that formal learning was an essential strategy to help nurses achieving their expectation competencies.
The majority of learning opportunities that the research participants identified were informal learning. In the situation of nursing education in Vietnam, which have been rare of formal nursing education programs in bachelor level and higher; informal learning was an essential learning strategy for nurses to use in order to enhance their competencies. There were several types of informal learning strategy identified by the research participants included continuing nursing education; learning with and through others (colleagues, role models, mentors, patients); learning from experience and self-reflection process; learning from mentoring or coaching; and self-study.
Continuing nursing educations, as learned from this study, included both in-service education, including both hospital and department levels, and out-service education, such as attending short training courses in nursing schools, workshops or conferences.
“I attended short courses that trained for nurses held by the hospital. In my department has also established continuing education classes trained for nurses of my department. We could propose the topics that we thought needed. Such as, the topic: reading ECG. We have been trained how to read an ECG. When perform an ECG for patient, we could recognize the informal signals in order to inform the doctors promptly…that is the ways we develop our competencies”. (ID 04)
Developing competencies by attending some particular patient education projects was also shared by the participants:
“We (nurses) have attended the front-line supporting projects…We have been trained through Face-to-face program. We are provided tablet computers which had been already installed needed programs by the doctors and we have been trained to address these. We then applied acquired knowledge and skills to provide education to our patients directly and answer for all concerns from patients. This program improved our knowledge and skills very much…We are very confident when educate to patients and their relatives. Be confident front of patients and colleagues…enhance our clinical knowledge and skills…” (ID 07)
Not only in-service training, out-service is also one of the important strategies that have been applied in order to enhance competencies among nurses practicing in the hospital.
“…We send them (nurses) to attend specific training programs, attend workshops and conferences that relevant to their field to improve their competencies of knowledge and skills…” (Stated the administrator medical doctor ID 13)
The research participants also identified and explained how the process of learning with and through significant others, including role models, colleagues, mentors, patients as well as significant others, assisted their improving competencies. Interestingly, not all participants experienced the same way of learning with and have been learned by others as a strategy of enhancing nurses’ capacities.
“I have learned from my colleagues...In many cases, I could not recognize these issues; however, others (medical doctors, nurses) they could recognize. I learned from their experiences. It’s very significant for my competency development”. (ID 09)
“I have learned from the nurse seniors…the knowledge and skills that I have gained from nursing school were not enough. Because each working environment is particular …not the same…I mean different diseases and issues. For example, I have learned from the seniors in my department who are experts in taking care of patients after skeletal surgery…how to recognize complications and solve difficult solutions” (ID 24)
Working in team was identified by all nurse participants as one of the most effectively strategies to enhance their competencies.
“…worked with others in a health care team would enhance my capacity quickly. If you just depend on your experiences without collaborating with other colleagues your competency would be improved slowly and you might not recognized your faults, you could not learn from other experiences. I have learned from my working in team with other a lot; such as how to organized the activities scientifically, how to communicate with others effectively, how to work in a group with others. I also observed experienced doctor’s performances to learn from him because he was an expert. I discussed with team members to find the appropriate way to care for patients… It’s the most important strategy to improve our nursing competency”. (ID 08)
Besides learning with and through colleagues in the same working facility, nurses also learned with and through colleagues from other hospitals or institutions:
“I often went to other hospitals to exchange experiences with my friends (the nurses working in others medical organizations). We went to coffee shops to enjoy and discuss together regarding our concerns, including sharing updated nursing information and experiences. I am very interested in this type of activities. We could share and learn from each other”.
Role model and mentoring were identified as significant figures in the journey of nurses of seeking knowledge, skills, and positive attitude as a good nurse.
“…You see, before working with them (the nurse seniors) I thought that I were a good nurse because I took care of patients with all my heart and so carefully. However, when I had opportunities working together with them I found that I was not good enough as my feeling. They took care of patients much better than me, more careful than what I did. They loved patients very much. I admired them very much and I love them. They gradually became my mirrors, became shining examples to me to follow…as role models. You see, they have brought knowledge, skills, caring as well as loving to me. I have learned… learned a lot of significant things through these role models”. (ID 02)
Attentively, numerous nurse participants described that the patients were the best ones who brought them knowledge, skills and significant experiences in their journey of enhancing competencies. The capacities of nurses would not be improved without learning from patients and family relatives. Furthermore, learning through experience and selfreflection were also significant strategies to improve competencies that the research participants experienced. They have learned from daily nursing activities, from particular situation, during taking care of patients and contacting with patients and others. The participants expressed that starting with the basic knowledge that they have been equipped in nursing schools, combined with experiences that they have learned every day at the field of nursing practice, needed knowledge and skills would be formed.
“I have learned from all my patients that I have cared for. I have learned from their issues, from the diseases or illnesses that they got. I have learned from the patients’ complaints or even they argued me, because from their complaints I would reflect myself and investigated the causes that made them to be unsatisfied…the patients and the relatives were the most significant teachers who improved my competencies”. (ID 04)
In order to improve competency, self-reflection was an important manner that the research participants described.
“I have improved my competency by listening to others’ comments and self-reflecting on this in order to do it better”. (ID 19)
“…I have learned from my working…self-reflection and learned from these. Even I learned from my mistakes. I reflected myself on that faults and learned from those…and I would do better”. (ID 09)
“…If you (nurses) just wait for help or supporting from others such as medical doctors or experienced nurses, it would not foster your capacity. You needs also self-reflect on your daily activities…” (ID 21)
Self-learning was another strategy that all participant concerned and applied in order to develop their individual competencies. Most of the participants indicated that, in the situation of overload working among nurses in Vietnam, they could not wait from outside supporting. Indeed, they should self-prepare in an effort of raising their competencies.
“We are so busy during our working shift…In some cases, I have questions however, I could not answer at that time, no one could help me to answer my concerns at the busy time. I then investigated myself by searching information from internet or reading books...” (ID 10)
The experiences shared from participants in the individual interview sessions were also supported by the data of focus group discussion and participant-observation sessions.
“In the context of lacking of bachelor and higher levels of nursing education in Vietnam, attending the short training course is essential to foster nurses’ competencies”. (FDG participant ID 17)
“…Burnt out…overload working…Not enough time to self-reflect on our work at working place, Just try to finish our tasks. So self-study, such as at home or every time we have opportunities, is a significant way of improving our knowledge and skills” (FDG participant ID 11)
During the fieldwork, the researcher had opportunities to company the nurse participants attending workshops and some particular short course training programs. Indicating that, informal learning was an important strategy of competency development among nurses practicing in clinical setting in Vietnam.
With a slot of rich information derived from participantobservations, in-depth interviews, and focus group discussions, the journey of competency development among nurses included both formal and informal learning strategies. Although there has been limited of bachelor as well as post graduate nursing education programs in Vietnam, all participants in this study viewed that formal learning was the trend and significant strategy that helped nurses to acquire advanced knowledge and skills. Furthermore, informal learning, including continuing nursing education, learning from working experience, learning from daily reflective process, and coaching and mentoring, was an important and indispensable way that the nurses applied during their journey of competency development.
The methods of improving nurses’ proficiencies, as identified by the participants, included both formal and/or informal learning strategies to help them improve their individuals’ competencies. Attending higher nursing education programs in nursing schools was identified as formal learning that nurses used to satisfy both qualification and competency requirements. In the situation of nursing education in Vietnam, which have been rare of formal nursing education programs in bachelor level and higher; informal learning was an essential learning strategy for nurses to use in order to enhance their competencies. The participants described that they have used a variety of learning situations to foster their capabilities that were identified as informal learning strategy included continuing nursing education, with both types of in-service as well as out-service; learning with and through others such as colleagues, role models, mentors, patients; learning from daily working experiences and self-reflection process; learning from mentoring or coaching, and self-study. Informal learning is an essential learning strategy for nurses to use in order to gain knowledge, skills and attitudes that will foster their capabilities.
Knowledge generated from this study was supported by the findings of previous studies. Nurses practicing in clinical settings used both formal and informal learning strategies to enhance their capabilities . In the study of Sharoff, the findings revealed that as the adult learners, nurse practitioners employing in clinical environments focused on using informal learning strategy to help them reach optimal competency . The informal learning strategy included various methods that facilitated the nurse practitioners to achieve expectation competencies. They acquired advanced nursing knowledge and skills through learning from their daily working experiences, learning from self-reflection on their practices as a nurse or clinical situations. The nurses also improved their proficiencies through mentoring, or learning from working together with colleagues and other significant healthcare personnel .
In the recent decades, Vietnam has opened the geopolitical boundaries to reinforce the relations with many countries. Socioeconomic in Vietnam recently has been dramatically improved. The health care needs have been increased quickly. The Ministry of Health of Vietnam has begun to concern and encourage as well as require nurses to advance their qualifications and capacities in order to response to the increasing of the health care needs . These have been one of the reasons encouraged nurses to improve their individual competencies by applying formal learning strategy to meet the requirements.
Informal learning is enhanced when individuals are proactive, creative, and engage in critical reflection . These characteristics were identified in this study as needed requirements to become competent nurses. Learning is a personal active process that entails an integration of knowledge and doing [9,10]. Nurses engaged in this personal activity by utilizing various strategies and then incorporating that knowledge into an action in order to learn to become competent individuals. Wan also indicated that learning from experience involves changing both what we do and how we see thing . The competent nurses need to be able to learn effective behaviors and gain meaningful interpretations of the experience because performance is the integration of knowing and doing , a learning where the nurse is actively engaged and involved. Furthermore, throughout selfreflection, nurses reflect upon the experience to develop an interpretation and understanding of the experience and then generate new skills, knowledge and attitudes that are brought into each new challenge and situation . According to Boud et al. (2013), what we learn from experience does not simply add new information, but transforms our way of experiencing .
Throughout process of interpersonal interaction with other was identified as one of the significant strategies the nurses has applied to enhance their capacities. This interpersonal relationship could take the form of learning with and through others, including colleagues, role models, mentors as well as patients and family care takers. Role models and mentoring were important to the nurses in their journey of selfcompetency completing. In an atmosphere of care and support, the role of mentor is to challenge student to examine their conceptions of self and the world and to formulate new, more develop perspectives . In order for nurses to become competent health personnel, needs for a connection with other significant individuals were concerned. Mentoring requires that both mentor and learner is critically reflective. Mentors who are able to critically reflect on their own experiences and learn from them are best able to model critical reflection in their mentoring interactions. Nurses intuitively seek out relationship with others, especially experienced health care personnel such as physicians or senior nurses .
In order for nurses practicing in clinical settings to improve their competencies, a variety of learning strategies they have applied. In addition to continuing learning both in-service and out-services and learn from and through from others, learning from daily working experiences and self-reflection process as well as self-study have been used. Strategies of establishing a variety of nursing education and training programs for nurses to develop their nursing competencies are implicated. Furthermore, facilitating nurses on their journey of enhancing nursing capacities is needed.
The main limitation of this study is that the study was undertaken in the context of only one national general public hospital. The contexts, working environments or nurses’ characteristics as well as the strategies of competency development among nurses practicing in other clinical settings in Vietnam such as specialty hospitals, provincial or district hospitals, private facilities, and etc. might have some differences from the studied hospital. It is recommended that further study should be included nurses in other working environments and across settings of the country. The knowledge generated helps further the understanding of significant ways that nurses practicing in clinical settings in specific socio-political and cultural contexts in Vietnam to develop their individual competencies. The appropriate strategies regarding the development of competencies among nurses practicing in clinical settings should be considered.
This paper was part of the research program conducted by Do Thi Ha in the fulfilment of a PhD degree in Nursing at Khon Kaen University, Thailand under the supervisor of Associate Professor Dr.Khanitta Nuntaboot. The researcher thanks all the participants who participated in the study and all persons who facilitated made this research possible.
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