Professional independence and postgraduate education of nurses

INTRODUCTION

Nursing is a profession that is constantly expanding, evolving, and changing. As a scientific field, it requires constant progress in research and scientific activities as well as work on changes in order to introduce them to nursing practice. After the implementation of the Bologna education system in 2004, education in Poland takes place at the level of three-cycle higher education, while post-graduate education is implemented according to principles, which are regulated by Article 66 of the Act on the profession of nurse and midwife [1] (specialisation training – specialisation, qualifying course, specialist course, skills improvement course). After completing postgraduate education, qualifications are ac-quired along with competences regulated by the Ministry of Health regulation of 30.09.2016 [2]. The intensive devel-opment of nursing as a science requires that nurses constantly update their knowledge and adapt it to the currently ap-plicable legal acts, scientific research, expectations of society and patients, and the dynamic development of new tech-nologies. Polish and world nursing is subject to constant changes as a result of ongoing modifications and development of all medical fields as well as changing demographic structures of societies, and thus a significant change in expecta-tions. As a regulated profession, nursing is also subject to legal regulations in the form of the Nurses and Midwives Act, which obligates people in those professions to constantly update their knowledge and professional skills in accordance with the latest medical knowledge, and guarantees the right to professional training in various types of postgraduate education [1]. Substantive, organisational and control supervision over the activities ordered by the Ministry of Health in the field of post-graduate education for Nurses and Midwives was entrusted to the Postgraduate Medical Education Centre of Nurses and Midwives, which operates on the basis of the Minister’s Order of 21 March 2012 [3] and the Main Council of Nurses and Midwives, which as a self-governing body implements the statutory obligation to exercise care over the proper performance of the profession imposed by the legislator [4] through a series of activities aimed at creat-ing legal and organisational conditions enabling continuing education of nurses and midwives. The current postgradu-ate education of nurses and midwives is based on the provisions of the Ministry of Health Regulation of 30.09.2016 [2] and a reformed education system for nurses and midwives. World trends strongly shape the direction of nurses’ training in the context of caring for the sick, and the education of healthy and sickness endangered people. Because nurses guarantee health care and health education of society in a professional manner and at low cost, it seems natural to increase the competence and professional independence of this group of employees. Nurses and midwives are obliged to analyse their professional activities in order to validate and evaluate the effects of actions taken in the context of their competences and professional qualifications. The necessity of lifelong learning within the profession is not only an expression of the legislator’s wish but, above all, a necessity resulting from the needs of developing medical knowledge in the field of nursing, both legislative and substantive [1]. The conclusions contained in the document Strategy for the Development of Nursing and Midwifery in Poland [5] underline the need for post-graduate education in order to gain professional independence of nurses and midwives necessary for the provision of so-called nursing advice guaranteed services by nurses and midwives [6].

AIM OF THE STUDY

Aim of the study is to analyse the professional independence of nurses after completing post-graduate education.

MATERIAL AND METHODS

The research covered n = 580 people from Poland. These people declared their participation in various forms of post-graduate education. The study used a diagnostic survey and used the survey technique. An original questionnaire consisting of 25 questions was placed in an electronic form on the Facebook social network, which brings nurses to-gether. Participation in the study was voluntary and anonymous. The research was carried out on 13.02.2019 and on 14.03.2019.

RESULTS

In the surveyed group 3/4 of respondents defined the “professional independence of a nurse” (Figure 1) as inde-pendent planning, implementation, and evaluation of the patient’s care process; 10.7% of respondents identified pro-fessional independence with independent professional nurses’ duties, and 4.2% with performing medical doctors’ or-ders.
The respondents were asked to indicate the form of postgraduate education they had completed (Figure 2) and the disposal of that which met the highest expectations in the range of competences and professional skills that can be used in their profession (Figure 3). More than half of the respondents indicated the completion of the specialisation (52.5%), and 56.65% of the respondents described the specialisation as the form of education that gives the greatest independence in the performance of professional tasks. Next in the respondents’ indications were qualifying courses (33.3%, independence – 9.33%) and specialist courses (29.4%, independence – 12.09%) vs. scientific conferences (18.8%, independence – 7.77%), as well as skills improvement courses constituting only a marginal percentage of choice (5.4%, independence – 2.59%). In the group’s replies there were also conclusions that there is no form of educa-tion that would have a significant impact on increasing competences and professional skills of nurses (13.6%, inde-pendence – 11.57%).
Regardless of their work experience (Table 1), about 1/2 of the respondents thought that the profession is fully independent and 47.6% that it is not. In addition, it is puzzling why people with work experience of 16-25 years (4.2%) and over 25 years (3.3%) had no opinion about professional independence.
People employed at universities and in long-term care (80%) are the most independent in their practice; 1/2 of the respondents employed at hospitals, schools medicine, and emergency medicine felt independent, similarly to more than half of the respondents employed at primary care clinics, specialist clinics, nursing homes, and hospices (Table 2).
The examined group, regardless of their work experience, thought that specialisation affected their professional independence; the group of nurses with more than 25 years of experience (103%) and 16-25 years more often (99%) thought that than did people with less work experience (Table 3).
Analysing the forms of education most useful from the point of view of professional independence, the study group working in the hospital (241) believed that specialisation gives the greatest sense of independence (Table 4).
About 3/4 of the respondents answered that professional independence in the case of the nursing profession is determined mainly by the Act on the Profession of Nurse and Midwife, although there were also responses indicating the place of employment (15.9%) and even the director/supervisor (16.7%) equally with the nurse (16.7%) the study group. n = 18 (3.1%) declared that they could not respond to the question (Table 5).
Among the factors determining the professional independence of nurses (Table 6) over 3/4 of respondents (80%) working in higher education units, school medicine, and long-term care identified independence with the Act on the Profession of Nurse and Midwife and the provisions contained therein clearly defining the framework of profes-sional activity in which nursing can function within the framework of individuality and self-deciding. This allows us to draw the conclusion that the established professional law is an inseparable component of the nursing profession and should be at the highest level. Shaping the framework of professional activity through the provisions contained in legal acts guarantees transparency and uniformity, ensuring reliability of the performance of the nursing profession.
Regardless of work experience, the study group believed that the current education system is unsatisfactory, nurses employed for up to 2 years, 2 to 5 years, 6-10 years, and 11 to 15 years (more than half of the respondents) had this opinion more often than nurses with work experience of 16-25 years (37.7%). The lowest number of objections to the current system of postgraduate education can be seen among people with work experience of over 25 years. This is confirmed by the significant statistical dependence p = 0.000. A significant group of respondents employed up to two years had no opinion on the current education system (36%) (Table 7).
The presented table clearly shows that changes in the education system are necessary, which was clearly de-clared by almost half of the respondents (47.9%), regardless of the place of employment. This trend is declared by more than 50% of respondents for whom post-graduate education is a significant contribution to increasing their rights and competences due to the workplace and duties such as primary care (52.3%) or long-term care (60%). The necessity of professional development and acquiring rights determines the need for continuous education in individual work with the patient (Table 8).
Based on the research, it should be noted that the vast majority of respondents were able to use qualifications they acquired during education (54.3%), and 33.6% even said that they knew all available competences provided for by law and could implement them into their professional practice. However, over 11% of respondents noted that this knowledge was not known to them or they could not use it in their professional work (Figure 4).

DISCUSSION

Expectations in relation to nurses are still growing in the areas of competence, education, and independence. It can-not be unnoticed, so changes expected by both sides have to be made. Postgraduate education is an indispensable ele-ment of professional development and as such, in addition to substantive values, should bring the expected competen-cies allowing for flexible activities in the area of market demand. Nurses, in addition to the fact that they must, as stat-utory provisions clearly state, update their knowledge, see the need for this and want to develop [7]. According to the Nurses and Midwives Postgraduate Medical Education Centre, progress in the scope of courses completed by nurses is clearly visible. For the example of specialisation, which is a master craftsman’s training in the profession, it can be seen that in the period 2002-2016 the total number of nurses and midwives who completed this type of course was 39,476, and in 2017 this number was by 10,638 people, which represents a more than three-fold increase in interest in raising their qualifications in this way [8]. The duty of the nursing community is to fulfil professional roles with great care and the highest level of professionalism [9]. Nurses making their choices about the types of education pay special attention to those that give them the greatest competence and skills, hence the interest in specialisation training, which apart from significantly increasing professional independence also allows financial rewards in the event of implementation by the Ministry of Health the Act on the lowest remuneration in health care [10]. Our own research indicated that 3/4 of nurses have a professional specialisation (Figure 2), and this trend is clearly growing. A well-educated nurse is ready to take on a specific professional role: a health guide and helper, carer, friend of the patient and his/her family, as well as a teacher capable of imparting knowledge and skills in health and illness [11].
Nurses want to educate, want to acquire new qualifications, and want to increase their professional skills, but they want to do it based on rules that are clear and that will also allow them to receive reliable financial rewards for acquired skills. The lack of specific solutions, including legislative ones, certainly does not facilitate these activities, and the proposals put forward by the Ministry of Health, e.g. in the form of a draft regulation on guaranteed services in the field of Outpatient Specialist Care, are certainly not those expected by the nurse and midwife environment [12]. In-creasing professional independence of nurses and midwives is a must, which the legislator must include in his/her legis-lative proposals, but in a realistic and reliable manner. Independent regulation of medicines and medical devices on the basis of art. 15a paragraph 1 of the Profession Act [1], providing having appropriate qualifications is going in the right direction, and people should think about whether to develop these and similar nurses’ powers and professional oppor-tunities to improve access to medical services. The nurse currently has the right to perform all activities listed in the Regulation of 28.02.2017.
Work experience does not significantly affect the identification of the nursing profession as an independent profession. Our own research does not indicate unambiguously that the team under study feels independent.
The abovementioned teams think of a different kind of independence, and therefore the conclusions drawn from the Strategy for Nursing [5] should be a starting point for thinking about the evolution of education, its significant modification, and with it acquired vocational competences [13, 14].
Nurses want to move towards an integrated coordinated care system, where the first qualifying element for the patient will be a nurse - educated, competent, independent, i.e. an advanced practice nurse (APN), working on the basis of scientific research (EBP) [15, 16].
Regardless of their work experience, about 1/2 of the respondents thought that the profession is fully inde-pendent and 47.6% that it is not. In addition, it is puzzling why people with work experience of 16-25 years (4.2%) and over 25 years (3.3%) had no opinion about professional independence.
However, it seems necessary that educational programs should be modified, as indicated by the Main Council of Nurses and Midwives (strategy) introducing the possibility of e-learning education, which will significantly facilitate access to education and reduce costs incurred by nurses and reduce educational modules, the highly developed net-work of which causes a chaos of competence [5, 17].
The fact that in most of the cases nurses, as indicated by the respondents, bear the costs of training, both fi-nancial and time-related, certainly does not help to improve their professional qualifications. Lack of support from the employer in the form of various facilitations and motivations is a problem that cannot be solved without clear regula-tions, including legislative ones [18, 19]. Suggestions for the establishment of training holidays, inalienable and belong-ing to a nurse, involved in raising their qualifications, are necessary measures to strengthen the motivation and willing-ness to participate in further education [5, 20]. The need for support and motivational actions on the part of employers is a significant element improving accessibility in developing professional competences, as well as regulations support-ing the financing of courses and trainings, as exemplified by the so-called ministerial specialisations entirely financed from the budget of the Ministry of Health [16]. As was shown by research conducted in 2008 by Tomaszewska et al. from the Medical University of Warsaw, 80% of respondents indicated financial constraints and high costs of post-graduate education as factors limiting their professional development [21]. Eleven years have passed, and unfortunate-ly not much has changed in this matter.

CONCLUSIONS

The nursing team is fully aware of the need to update knowledge and skills, because it has a big impact on their ability to gain independence, which is given by the acquired qualifications in the provision of services to the patient and the family.
New competences require knowledge and practical skills acquired during practical training [21–23].

Disclosure

The authors declare no conflict of interest.

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