Challenges of postgraduate emergency nursing program in Iran: A qualitative study.

BACKGROUND: Some nursing schools in Iran with the aim of training qualified nurses have set up master's degrees in emergency nursing. In any case, there are challenges in the implementation of this discipline in academic nursing centers which prevent the fulfillment of goals and missions in the curriculum.
MATERIALS AND METHODS: In this qualitative study, four graduates of the master of emergency nursing and 13 undergraduate students were purposively recruited from the Nursing and Midwifery Faculty in Qom, Iran. Data were collected through semi-structured interviews and analyzed through conventional content analysis.
RESULTS: Emergency nursing master's program challenges consist of two categories: nonproductive course design and unresolved infrastructure. The extracted subcategories were unfit curriculum, inappropriate content, nonspecialized program, unclear roles, improper course planning, unskilled human resources, and poor educational facilities.
CONCLUSION: Based on the experiences of nursing graduates, the curriculum of master of emergency nursing in Iran needs to be substantially revised in terms of content and structure. Copyright:

Introduction

The postgraduate emergency nursing program is one of the specialties in nursing.[1] Prerequisites for entering the master's degree program in emergency nursing are having a bachelor's degree in nursing and at least 2 years of clinical experience.[2] Graduates in this field should be able to act independently based on the evidence-based emergency services.[345] They must be able to communicate professionally with the patient and other emergency teams to quickly diagnose and manage health problems in traumatic injuries and in chemical and nuclear disasters.[6789] Other graduates’ duties include planning and managing emergencies according to the needs of the victims at the accident scenes, training of clients, families, and participation in applied researches.[101112] In addition, graduates are expected to play a key role in shaping the foundation of health-care delivery in emergency and critical accident situations.[13]

Due to the development of specialized nursing fields in Iran, emergency nursing was approved by the secretariat of the medical education council in March 2011. But so far, few nursing colleges have been involved in emergency nursing education. Furthermore, the lack of experience in providing educational courses related to the field, it has made it difficult for nursing educators and students in implementing the curriculum effectively. This can be complicated due to the gap in effective knowledge production with up-to-date technology which brings difficulties in the management of the educational courses of professional master's degrees in nursing. In this regard, Munari et al. in analyzing dissertations provided by MSN graduated students suggest the programs of master's degrees in nursing, need to integrated by innovative professional practices to meet the health-care and educational areas.[14] In discussing the problems of postgraduate nursing, studies suggest a variety of findings. Havenga and Sengane identified personal, academic, institutional, and research-related challenges in postgraduate nursing students at a South African university.[15] Aghebati et al. show the experiences of critical care nursing students and lecturers. The ambiguity on internal regulation, effort to establish a professional identity, limitation of expert human resources, and student's heterogeneity all were the challenges in the implementation of master of critical care nursing curriculum.[16] Nikfarid and Ashktorab determined NICU master students had ambiguities role for their specialty positions; the lack of proportionality in the curriculum, frustration after the entrance, unprepared clinical fields for the profession.[17] Dehghan Nayeri et al. suggest the necessity to review the curriculum in postgraduate critical care nursing due to challenges in designing and implementing the program, as well as inefficiency and inadequacy in nursing educators.[18]

The emergency nursing master's curriculum has been running since 2015. The reality is that the challenges of this field are not very clearly explored. Therefore, in this qualitative study, the researchers explain the strengths and weaknesses of MSN in emergency nursing from the perspective of students and graduates.

Materials and Methods

For a deep understanding of the challenges of graduates and students of MSc in Emergency Nursing, this study was conducted in a qualitative approach with a conventional content analysis method. About 17 participants were selected by purposeful sampling with a maximum variation of gender, marital status, and clinical experience. Sampling continued until data saturation.

Data were collected from March 2018 to February 2019 through face-to-face in-depth individual semi-structured interviews. All interviews were conducted in Persian by the first author. All interviews were coordinated with the participants in terms of time and place. The average duration of an interview was 30 min. Researchers used open-ended and probing questions: “what were your experience of starting the course?,” “what was your expectations for the MSc in Emergency Nursing?” Have your expectations been fulfilled in the course? “Please quote your experiences of the strengths and weaknesses of the course.” Please describe one of the classroom sessions that you found to be effective?, “Please describe one of the class sessions (theoretical or clinical) that you think it was ineffective?”

Data obtained from the interviews were based on conventional content analysis.[19] All interviews were audiotaped and transcribed verbatim. After reading the text of each interview, the words, sentences, and paragraphs were extracted as meaning units. Meaning units were abstracted as coded. The codes were abstracted according to their similarities and differences to subcategories, categories, and finally, the theme extracted as an expression of the latent content of the text.[20] Data saturation was met when no new concepts emerged from subsequent interviews.[21] The criteria proposed by Lincoln and Guba were used for the trustworthiness of the study.[22] Prolonged engagement with the data and member checking was considered for credibility. Moreover, dependability was established by peer checking; coauthors reviewed and confirmed the accuracy of data analysis. To ensure conformability, external auditing was adopted and all steps of the study were clearly described. Finally, transferability was applied through maximum variation sampling. This manuscript is the result of a research project approved by the Ethics Committee of Qom University of Medical Sciences (Code: IR. IMUQ. REC.1397.138). Informed verbal consent was applied for each participant. The purpose of the study, the method of data collection, the recording of interviews, the voluntary participation, and the right to withdraw from the study were described verbally to the participants.

Results

The demographic characteristics of the participants are presented in Table 1. Emergency nursing master's program challenges consist of two main themes: nonproductive course design and unresolved infrastructure [Table 2].

Table 1

Demographic characteristics of the participants

Participants	Age	Gender	Marital status	Clinical experience (years)	Educational status
1	39	Female	Single	11	Graduated
2	36	Male	Married	10	Graduated
3	29	Female	Married	6	Graduated
4	28	Female	Married	5	Student
5	34	Female	Married	4	Student
6	30	Female	Married	9	Student
7	29	Male	Married	10	Student
8	26	Male	Married	5	Student
9	30	Male	Married	8	Student
10	38	Male	Married	8	Student
11	40	Female	Married	11	Student
12	42	Female	Single	17	Student
13	40	Female	Married	11	Student

Table 2

Challenges of postgraduate emergency nursing program

Categories	Subcategories
Nonproductive course design	Unfit curriculum
	Inappropriate content
	Nonspecialized program
	Unclear roles
	Improper course planning
Unresolved infrastructure	Unskilled human resources
	Poor educational facilities

Nonproductive course design

This category consists of five subcategories: unfit curriculum, inappropriate content, nonspecialized program, unclear roles, and inappropriate course planning.

Unfit curriculum

All participants pointed to the lack of fitness in the emergency nursing master's curriculum that the curriculum was not responsive to the academic, research, and management needs of students. “The curriculum is weak and needs to be reformed. Instead of all the coursework and training, it would probably have been more effective if we had more theoretical units” (P4). Another student quotes: “I think the curriculum in master of emergency nursing doesn’t have a single protocol and this weakness should be corrected” (P7), “I think it would be useful if a percentage of shifts were devoted to research in emergency nursing and participation for the training of undergraduate nursing students” (P1). Students emphasized a review of the quality and content of the course. They believed many of the educational materials in the curriculum overlapped with BSN. In this regard, a graduated nurse said: “There was a lot of duplicate content, and the teachers said that a good reference was not yet available. Unfortunately, the teachers were really confused and they didn’t know exactly what to teach us” (P3). Furthermore, a student quoted: “Weakness of educational programming such as shift work leads to duplication and our delay to complete the MS thesis” (P12). Participants noted some classes did not have enough hours. Students cited the challenges of internship shifts. In this regard, a participant said: “our time is wasted a lot with the current curriculum, especially when we are in shifts” (P6). Students stated that the course design was not sufficient to work in emergency situations. In this regard, a student said: “Tasks are still unclear on how the internships will be implemented” (P8).

Inappropriate content

Participants founded that the course is inappropriate. They believed that the content would not lead to a skilled nurse in the emergency situations. They stated that this content is far from the original nature of emergency nursing. In this subject, a student quoted: “The content is inappropriate. The teacher while teaching heart disease did not know whether to teach prehospital materials or the hospital emergencies. So, the materials are confusing” (P13).

Nonspecialized program

All participants spoke of the nonspecialized program in the course. They expected the courses to specifically address emergency cases. They believed that in addition to overlapping the course materials with those taught in undergraduate, the specialized aspects of some courses were less emphasized. One student said in this regard: “Whether it is a prehospital or a hospital emergency, each has its own specialty and cannot be integrated. So, the full content of each is not fully considered” (P9).

Unclear roles

Students cited ambiguity in their role and position in the profession. They believed that their time was wasted due to the lack of clear role in the hospital. One of the graduated students said: “Sometimes we were treated like an undergraduate in the emergency department. We had to do trivial things; while we had clinical experience” (P2).

Inappropriate course planning

All students pointed to weaknesses in the course planning. In relation to this topic, a graduate student said: “lack of proper planning created challenges in the first semester and we had difficulty adjusting the courses” (P1). Another graduated student said: “crisis management was taught by several professors, which seemed to be due to lack of planning and coordination” (P2) One of the challenges students faced with course planning was the lack of coordination between university and hospital officials. On this issue, a student said: “Although I have applied to the dormitories twice and also I have written a letter, I complain about student affairs” (P10).

Unresolved infrastructures

This category consists of two subcategories: unskilled human resources and poor educational facilities.

Unskilled human resources

All students reported the lack of the necessary infrastructure as one of the major challenges in implementing a master's degree in emergency nursing. As the MSc in emergency nursing has recently been added to the specialized nursing disciplines, so many nursing educators have not completed relevant courses in this field. Thus, the shortage of skilled and experienced staff is one of the challenges of implementing education programs. Participants had quotes in this regard: “We had a shortage of experts and skilled nursing educators.” (P3), “I expected the professors to have very good and comprehensive information that was not really the case and some professors were not trained to teach in the emergency room.” (P11), “curriculum was implemented with nonspecialist and nonprofessional teachers.” (P2), “The academic field of some professors did not fit the curriculum.” (P3) “We had a professor whose specialty was medical surgical nursing and taught us emergency management.” (P1) “When I was asking the teacher a question outside of the lesson, she was confused and I would rather not ask again.” (P7), “Some of the teachers were so scattered that we didn’t have any notes at the end of the semester.” (P2).

Poor educational facilities

One of the participants’ challenges was inadequate educational facilities. For example, separate and equipped classrooms, textbooks, computers, and printer. One of the graduated students said in this regard: “One of the four computers was usable; the classroom facilities were bad; Due to the constant exposure to sunlight in summer and annoying cold in winter, with constant noise outside the classroom. The library was not up to date and the books were not sufficient and relevant. There was no dissertation in the library.” (P2) Furthermore, participants talked about the lack of the facilities in dormitories, transportation, and meals. A participant said: “our student residence was outside the city. We had no service to the campus and dormitory.” Another student said: “We have trouble getting food at the time of the hospital shift. Also, in the hospital, we do not have access to the Internet for quick access to the required information.” (P5).

Discussion

In exploring the challenges of postgraduate emergency nursing course, students experience infrastructure and executive challenges. In the meantime, the incompetence of the curriculum is experienced by students as the most important challenge. Students show the curriculum in education, research and management is inadequate and they believe that the graduates don’t have the necessary qualifications to work in the emergency department. Some of the shortages include overlapping of the curriculum with undergraduate courses, duplication of topics, superficial content, and inadequate attention to field-related topics. Nikfarid and Ashktorab in the neonatal postgraduate study identify inadequate curriculum and repetition of some units as students’ perceived challenges and cause of their dissatisfaction.[17] In this study, participants highlight the low fit of the courses offered with their specialty needs. In this regard, the authors believe that determining the professional competence of graduate nurses is not as priority in the specialized program in nursing education programs. Furthermore, unresolved infrastructure is recognized as a challenge for the emergency nursing course in Iran. This finding can be rated to lack of holding the registry nursing examination to determine the scientific and practical competence of nursing graduates. In line with our findings in infrastructure challenge, a comparative study shows differences in the admission requirements, goals, philosophy, mission, vision, course content, the role of graduates, having nurse practitioner, spaces, and abilities, and administrative staff were different in Iran and John Hopkins School of Nursing, America.[23] One of the findings of this study is that students are confused and ambiguous about their professional role in emergency nursing. The origin of this ambiguity is related to the lack of protocol and uniformity in teaching and unclear tasks in internship practices. Since the graduates of this course are expected to act as a skilled and competent nurse in emergency situations, in general, participants stated of a nonspecialized curriculum. Regarding to development of an emergency nursing training curriculum, some countries have prepared interactive programs for their nursing schools. For example, the results of a unique collaboration between a university in the United States, a Ghanaian universityand a Ghanaian educational hospital show that educational programs for the emergency nursing course including an innovative, interdisciplinary and team-based clinical training model, unique and low-resource emergency nursing curriculum, and comprehensive training program to increase retention of nurses.[24] Based on the findings of this qualitative study, researchers suggest that nursing officials in the Ministry of Health could benefit of the other countries’ experience to solve the structural and executive challenges of emergency nursing course. It is also recommended that more accurate studies be carried out before the launch of the course in terms of determining the competence of instructors and academic and hospital facilities.

Conclusion

Since the Master's Degree in emergency nursing is relatively new in Iran, the researchers point to the emergency nursing curriculum needs to be revised based on the daily needs of the community and the experiences of the educators, graduates, course planners, and relevant authorities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.