| Abstract |
Introduction: The present action research study was conducted to contribute
to primary health care (PHC) planning within the 7th Regional Health System
of Crete. The methods “job analysis” and “needs assessment” were used, as
suggested by the international literature for effective human resource
management.
Aim: To describe nursing practice in regards to roles, clinical tasks,
responsibilities and to explore continuing education (CE) needs, on-the-job
training and professional development of nursing staff employed in primary
health care centers (PHCCs) of Crete, as well as to formulate
recommendations.
Targets: 1) To describe demographic characteristics, individual abilities and
job performance of nursing staff employed in PHCCs of the 7th
Regional Health System of Crete.
2) To explore duties and responsibilities (roles, clinical tasks and
scope of practice) in terms of frequency and self-assessed
competence based on educational preparation (2 year vs. 3 or 4-
year degree) and professional category.
3) To explore the applicability of a standardized, international tool
assessing on-the-job training needs in Greek PHC settings,
following translation, cultural adaptation and validation.
4) To assess attitudes and perceptions of nursing staff in regards to
CE and on-the-job training.
5) To assess CE needs according to educational preparation and
professional category.
6) To explore professional development needs (administrativesupportive,
technical-resources, organizational).
7) To formulate recommendations and measures that would lead
to improved PHC nursing care throughout PHCCs in Crete.
Subjects and methods: Target population was all nursing staff (registered
nurses, midwives, health visitors and and licensed practical nurses) of all
PHCCs and 121 Satellite Clinics of the 7th Regional Health System of Crete.
Data collection was completed in two phases. During phase 1, the original,
validated questionnaire “Assessment of Nursing Practices and Needs in Primary
Health Care” was used and 92 completed questionnaires were returned.
During phase 2, the translated, culturally adapted and validated tool
“Training Needs Assessment” was used and 55 questionnaires were completed
and returned. Data from both phases were analyzed statistically, according to
educational preparation (group A=2-year degree graduates, group B=3 or 4-
year degree graduates) and professional category, as well as qualitatively,
according to the content analysis method.
Results: There were serious understaffing (49.5% vacancy rates) and skill mix
issues in all rural units, with licensed practical nurses (LPNs) being the most
numerous (41.3%), in contrast to health visitors (5.4%). In regards to everyday
practice, there were no statistically significant differences among nursing
professionals according to educational level or category. Only exceptions
were the counseling role which was assumed less frequently by LPNs
(p=0.01), the teaching role which was assumed more frequently by midwives
and health visitors (p=0.03) and obtaining a patient’s health history which
was undertaken less frequently by RNs and LPNs (p=0.04). Holders of a
nursing specialty certification differed in terms of the frequency of counseling
(p=0.04), assessment of risk factors (p=0.04) and home care visits (p=0.02).
The most important recruitment incentives were the unit’s reputation (73.9%)
and residence (71.7%) or origin (65.2%) from the unit’s catchment area. The
most important reasons for dissatisfaction were the lack of opportunities for
professional development (65.2%) and lack of everyday support (62%).
Deficits in human resources (53.6%) and equipment-supplies (36.2%) were
reported as major obstacles in job performance.
Professional development opportunities were very limited, fragmented and
offered mostly off-site. Although the majority of staff had a positive attitude
towards CE, family obligations, distance of CE site and lack of free time were
identified as primary barriers. Inability to speak English, lack of basic
computer skills or facilities and absence of professional guidance were all
implied hindering factors.
Self-assessed competence from both study phases was high, regardless of
educational level or position held. Exception were midwives who in
comparison to RNs exhibited higher competence in select activities, such as
“gaining access to literature related to clinical work” (p=0.019), “statistically
analyzing own data” (p=0.052) and “undertaking health promotion activities”
(p=0.01). In terms of importance of assigned tasks , there were no significant
differences between group A and B, except of the following two tasks rated as
more important by group B: “communicating with patients face-to-face”
(p=0.034) and “undertaking health promotion activities” (p=0.043). Last, job
importance and level of performance for research/audit activities differed
according to professional category (p=0.039 and p=0.001, respectively).
During phase 1, the top 3 training priorities included “emergency services”,
“screening programs”, “prevention-health promotion” and “ethics”.
Individual ability to use a computer, roles and responsibilities assumed and
the scope of nursing practice were significantly related to priority level
assigned to specific training needs. During phase 2, significant differences in
training needs emerged on 14 tasks for the whole sample, categorized into
research/audit, clinical, management/supervision, communication/
teamwork and administration/business related activities. Training needs did
not differ according to age or work experience.
The psychometric properties of the Greek version of the TNA questionnaire
for nursing staff employed in primary care were good. Internal consistency of
the instrument was very good (Cronbach's alpha=0.985 p<0.001) and Kappa
coefficient for reproducibility was found to be 0.928 (p<0.0001). Significant
positive correlations were found between respondents’ current performance
levels on each of the research items and amount of research involvement,
indicating good criterion validity in the areas tested. Factor analysis revealed
seven factors with eigenvalues of >1.0, KMO (Kaiser-Meyer-Olkin) measure of
sampling adequacy = 0.680 and Bartlett’s test of sphericity, p<0.001.
Discussion-Conclusions: Analysis of select variables portrayed with clarity
PHC nursing practice and professional development needs of nursing staff
employed in PHCCs throughout Crete. Everyday practice focused on
technological care and the clinical role, whereas health promotion and
prevention activities were carried out occasionally and opportunistically.
Professional characteristics and level of performance among the four
professional categories were similar, with minor differentiation, whereas
statistically significant training needs were identified for all nursing staff,
with minor differences among the four categories. Training in research/audit
skills was rated as the most needed, along with continuing education in
emergency nursing care, prevention, health promotion and screening
programs. Critical issues for effective human resource management in rural
settings included: understaffing and skill mix unbalances, difficulties in
recruiting personnel with more advanced educational preparation, limited
professional development opportunities, absence of resources offering
support and consultation at work, role confusion/conflict and last, failure to
implement a health team approach.
Based on study findings, strategic planning at a regional level of continuing
education and on-the-job training needs is essential in providing a standard
framework for professional development, investing in trainees’ positive
attitudes and in the “Training Needs Assessment” tool, found to be suitable for
Greek PHC settings.
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