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		THEORY AND METHODOLOGY
		The development and evaluation of a course on quality guarantee for nurses. The History of a Thesis Areti Stavropoulou Ph.D., MSc, RN. Technological Educational Institution of Athens, Faculty of Health and Caring Professions, Department of Nursing. Antiohias 5A.17123 N.Smirni, Atenas (Grecia) Manuscript acepted by 18.4.06 Temperamentvm 2007; 5
How to cite this document
Stavropoulou A. The Development and evaluation of a course on quality guarantee for nurses. The History of a Thesis. Temperamentvm 2007; 5. In </temperamentum/tn5/t1606e.php> Consulted

Abstract This article is the outcome of the author's critical thinking about her experience with nursing students. Her PhD thesis was developed at the School of Nursing and Midwifery of the University of Cardiff, between 1997 and 2003, under the inspiring supervision of Dr. Patricia Lyne, Consultant Research Professor. The work introduced in this brief article attempts to show how her initiative, in a modern context, brought about a whole process of questioning, solution searching and, modestly, developing of new knowledge.

Short Presentation

"Under a boundless, clear blue sky, the ancient philosophers are standing, as kings in their kingdom, surrounded by a bunch of young, handsome, decent students, eager to learn. We are in Athens. Their names, Plato or Aristotle. It is the dawn of a new era, the dawn of the contemporary society. Peace and serenity. If some arguments exist they are clearly at an intellectual level. Reflective. Statements versus statements. Disputatio".   
Cauquelin 1996

     This portrait, which so beautifully depicts the intellectual climate in ancient Athens, has some similarities with our era. Plato and Aristotle do not exist as physical persons, but their spirit, their arguments and their philosophical thinking are spread everywhere, influencing many modern philosophers, the scientific roots for most of the disciplines and the development of new paradigms and scientific theories. Physical death for them was exactly what Schopenhauer stated before his own death: "the dark of my life will be the light of my glory". Professors and teachers are still standing surrounded by young, decent students. The students are still eager to learn. They are required to critically appraise scientific literature, to present statements versus statements, to be reflective and discussive. To initiate and participate in disputatio (Latin: Discussion, dialogue).

Although there are many differences between the two historical times, the process of learning, of developing knowledge, of questioning the given and of unfolding philosophical inquiry, remains the same, even though the subjects being debated change according to the times. The work presented in this short report, is an attempt to show how an enterprise in a very modern setting gave rise to a process of questioning, searching for solutions and, in a modest way, developing new knowledge.

In 1997, in a rather boring and dark classroom in Athens, as a nurse teacher, I faced a group of talented but deeply disappointed nurse students who were reflecting on the vanity of their efforts the same way as the Trojans did in Kavafy's poem¹. Although they were ready to fight in order "to get somewhere, to grow almost bold and hopeful... something always comes up to stop them". For them, the challenge was their need to search for knowledge, to move forward, to walk against obstacles, to argue, to explore philosophical thinking, to participate in disputatio. It was also a challenge and a responsibility for me to participate in this phenomenon and to explore it. However, the challenge proved very difficult.

This work is founded on the evaluation of an innovative programme for nurse students in Greece. The subject area chosen was quality of care, a topic that had received much recent attention in Europe but was, at the same time, neglected in the Greek health care setting. It was an area referred to in the ancient texts of Hippoctrates as the means of providing holistic and excellent care to individuals. It encompassed concepts of structure, process and outcomes, change and improvement². The selection of this area was significant because it gave the students the opportunity to participate in a new development, to be active players, to feel that their efforts can be rewarded, "to grow bold and hopeful".

For the researcher, evaluation of this programme would be an opportunity to explore the learning process, the experiences of the participants, how things develop, which parts of this developmental process are effective and which can be improved. The theme was ideal because involved a new development for nursing and a new opportunity to learn about evaluation.

The educational programme was provided to graduate nurses. The first step in the study was to assess the existing knowledge of the target population regarding issues of quality of care. This would be a way of exploring what exactly participants already know and of what nurse students want to know, so that according to the adult learning theory, they would be receptive to the new knowledge³.

The content and schedule of the learning programme were based on the data obtained and relevant literature on quality of care, standards and criteria, accreditation mechanisms, monitoring and evaluation, clinical outcomes, models of change and improvement.

At this time, the work was guided entirely by the predominant scientific paradigm which informs experimental evaluation.  For the novice researcher a concept that is widely accepted and recommended by respected persons has great authority. Many centuries ago, Aristotle with his usual ironic sense of humour had realised that acceptance and recognition are the most significant ingredients of authority⁴. It is difficult for the novice, enthusiastic researcher to come to the same conclusion.

The students selected for the learning programme were twelve graduates, skilled nurses highly motivated to learn and to participate in new developments, with great expectations. They were required to travel to UK, as the programme was developed in Cardiff. They stayed in the University Campus for one week, during April 1997. This in itself presented interesting issues. The language, the culture, the personal interactions, the environment, the way of life -so different from the "smooth" Athenian environment, which adores expressive talking, continuous changes of plans and opinions, enthusiastic storytelling and free schedules- were all of significance to the study.

During the learning programme, the setting, the activities, the participants and the actual scheduling were monitored. However, the main focus of the evaluation was on the aspects of the programme capable of yielding quantitative data, such as outcome measures. Fortunately, when some years later, the focus of evaluation changed, data from that monitoring was available to highlight underlying mechanisms, strengths and weaknesses of the process followed.

At the conclusion of the programme, data were collected to assess changes in attitudes, and knowledge. The results of this outcome-based evaluation were discussed in the light of the prevailing views in the area of quality of care. However, the end result of the process was disappointing. Little, if any, change was detected in self-reported knowledge, skills and attitudes and little was learned about the factors responsible for this outcome.

The inevitable conclusion was that the initially designed approach to evaluate the educational programme was inappropriate. The focus on group outcome measures had restricted the development of knowledge on human experiences, intellectual growth, people's perspectives and interactions. The initial approach to programme evaluation had neglected the human element of the programme. Moreover, the design was less than adequate in scientific terms, such as the number of respondents and the control of experimental variables.

In the light of this inadequacy, a reconsideration of the evaluation approach and a further exploration of alternative evaluation designs were made. The focus shifted to process, rather than outcome. Interpretation of data took into consideration the culture of the participants and its effect on the programme's development, introduction and implementation. Emphasis was placed on how people's experience influenced the learning process or the outcome of the programme, how the context and other human related elements affected the process of introducing the programme.

The focus of the study therefore shifted from a quantitative to a qualitative perspective. This involved a re-interpretation of all the original data collected at the time of implementation together with new retrospective data and personal reflection. The involvement of the stakeholders in the process was of critical importance.

It may be argued that the above elements can not provide rigorous scientific knowledge. In qualitative research, though, knowledge development is achieved by exploring opinions, feelings and experiences. For this reason qualitative research has been characterised as a "soft science", in contrast to the quantitative research, the "hard science". This distinction led to the eternal debate between positivism and naturalism^5-6. A similar debate between Plato and Aristotle concerned "opinion". For Plato as long as opinion can not be subjected to rigor and control, it can not formulate scientific knowledge. For Aristotle, opinion has a special interest and meaning. It reveals the real, something that is recognised and accepted from everyone as a true value and it monitors the possible.

After experiencing the unsuccessful effort to evaluate the programme, I had to question everything. What is knowledge, where does it come from? What is science, from whence its strength and authority? Should we believe and follow its directions?

The attempt to address these questions was made in parallel with the search for a new evaluation approach. By the end of this process, I realised that I had trodden the same path as other evaluators who adopted the title "emergent realists"⁷. The thesis describes the journey from experimental to realistic evaluation. It is available in the library of Cardiff University, School of Nursing and Midwifery Studies, hoping that this learning experience with its frustrations and enlightenment will produce interest and motivation as well as salutary warning to researchers in this field.

References

1. Kavafy C. Poems A (1896-1918). Poiémata A (1896-1918). Ekdoseis Ikaros: Ikaros Publications, 1963.
2. Donabedian A. The definition of quality and approaches to its assessment. Explorations in quality assessment and monitoring, Volume I. Ann Arbor: Health Administration Press, 1980.
3. Knowles MS. A modern practice of adult education. Adragogy v pedagogy. UK: Association Press, 1970.
4. Cauquelin A. Aristotle. Editions du Seuil. Aristóteles: Ekdoseis Papadéma, 1996.
5. Burns N, Grove SK. The practice of nursing research: conduct, critique and utilization. Philadelphia: Saunders, 1987.
6. Leach M. Philosophical choices. Nursing, 1990; 4(3): 16-18.
7. Pawson R, Tilley N. Realistic evaluation. Thousand Oaks. CA: Sage, 1997.

 

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