Aproximaciones al concepto de raza

The qualitative data stem from open-ended questions, including: What are the skills that are most needed to provide health education? and What are the subjects of knowledge most needed to provide health education? The qualitative data findings provide two themes that could explain why, in this study, the previous quantitative data found that the majority of measured knowledge and skills were important and needed for health education. Those include: required leaning needs and education-related problems of health education. The appendix 5 (p. 274) summarises the qualitative analysis of the main themes and their subcategories. The required learning needs include general comprehensive and some specific subjects of knowledge and skills in health education. The education-related problems of health education include language inconsistencies in nurses’ education in health education, inadequate training being provided and lack of training. While the learning needs might be an expected factor, the role of language inconsistencies in nursing education was unexpected.

6.3.2.1.Theme 1 – Learning needs of health education

The most noticeable factor within the qualitative data findings is the type of learning nurses require to deliver hospital-based health education. The findings indicate that nurses are in need of two types of learning needs, which include: Comprehensive subjects, such as the knowledge and skills for health education practice, and the other type is the need for specific subjects and skills for health education.

6.3.2.1.1. General comprehensive education in health education

The comprehensive learning needs mean general systematic education/ training that covers many subjects and skills related to health education, and this training/ education this has to be based on several tools and strategies for systematic education/ training in health education. This factor was mentioned by five participants, including two nurse supervisors, two nurse instructors and one staff nurse, who all believe that nurses need more lectures, courses and continuous medical education about health education to ensure that nurses get the knowledge they need to engage in optimal practice in health education. A supervisor (5/FL/S/M/ED) stated that, “Nurses need to read everything new about health education, publications and the most important continuous medical

education, as it should present everything new about health education. The required

skills are varied, and sometimes based on the patient’s condition, for example nurses may be required to learn how to decrease their level to the patient's literacy level to ensure that the information provided is understood.” hence, it is possible as well as direct knowledge, nurses need practical skills for learning in order to provide health education by using the on ongoing basis, learn independently and keep up to date. Also another participant (16/FL/NS/M/sup) stated: “They have to be educated about medicine, diet and everything, they need lectures, a staff development programme, things like that we have to provide. The knowledge they should get is the importance of health education … we have to have more information about that one (health education), then they will know and they will provide it.” Hence, this finding suggests that health education requires a wide range of knowledge and skills. This result also could be an indirect validation of the following quantitative results, and this can explain why the majority of knowledge and skills measured by survey of this study are perceived to be highly important because, simply, they need them.

6.3.2.1.2.The need for specific knowledge of and skills in health education

The other type of learning need is the need for specific subjects for education. The findings also indicate a need for specific learning subjects to improve of daily practice of health education, and the most reported specific learning need is knowledge of Arabic and English from language-training courses, which was previously mentioned in the qualitative data findings. This subject was demanded and linked to the language barrier that affects both Saudi and expatriate nurses; especially the next section, about

barriers to health, will clearly indicate that language is a real daily challenge for nurses. The need for Arabic and English language training courses was mentioned by six participants, including staff, managers, Saudi and expatriate nurses. A nurse (9/FL/S/ST/NW) stated, “It’s good to provide expatriate nurses with Arabic training

courses, but also Saudi nurses require more training courses in English”. Also, a

participant (6/ml/ns/m/ins) stated, “Here, as a nurse, you should be somehow be good at speaking in Arabic and English because not all patients are Saudi patients.”

The findings also identified some other additional specific learning needs, such as teaching/ instructing, management, and knowledge of social and cultural values, which was previously mentioned in the quantitative data findings. A clinical instructor (14/fl/ns/m) for example, said, “social education has to be included in their studies … also patient teaching should be included in future nursing education because nurses

have to do health education”. And someone (17/fl/M/IC) talking about health

education said, “There should be a continuous education programme, including management, that covers everything.” It may not be appropriate to conclude directly that these subjects of knowledge and skills (teaching/ instructing, management, social and cultural values) are shared themes as each one of these subjects was mentioned by only one participant, except for teaching/ instructing which was mentioned by two participants; but in consideration of the previous findings which indicated that nurses are in need of comprehensive education in health education, it could be possible; and in consideration of these previous subjects also being identified by quantitative data findings as important skills, it is possible to say that it is part of the learning needs demanded for health education. This comprehensive education in health education is, however, not the only challenge to hospital nurses; the following factor, which is about the quality of health-education training or continuous medical education, may also play a role in explaining the previous quantitative results.

6.3.2.2. Theme 2.educational related problems

6.3.2.2.1. Role of language inconsistency in nursing education

The findings indicate that there is a low level of confidence due to the language inconstancy between nurses as learners and their instructors during their nursing education. This finding relates more to Saudi nurses than to expatriate nurses, which is

originally due to the language barrier, as was previously mentioned in the quantitative data findings. This factor was only mentioned by nurse managers.

This is because, in Saudi Arabia and unlike Saudi hospitals, all public schools education is conducted only in Arabic with very limited courses in English starting in elementary school until the end of high school. The public media often report inadequate and ineffective English education in Saudi public schools. Even some nursing schools and colleges are teaching nursing in Arabic. Hence, a Saudi nursing student who studies and graduates as a nurse suffers from receiving nursing education in English, as the official language in Saudi hospitals, especially nursing education in hospitals, is often determined by non-Arabic speakers, i.e. expatriate nurse instructors. This means that when nurses graduate they are sometimes ill-equipped to speak in English, which is the language of hospital practice.

As a result, this decreases students’ and new staff nurses' ability to receive education from one side, and affects the ability of nurse instructors to educate student nurses, thus making it more difficult for the instructors to evaluate nurses' skill in giving health education. As result, it affects the outcomes of the education/training provided for nurses and affects their confident levels in their ability to teach. This means that this problem relates more to Saudi nurses than to expatriates nurses.

Four nurse managers validated this issue. A clinical instructor (10/FL/NS/M/TNSI) stated that, “It's difficult to do education if there is language hindrance, even if I teach, they cannot comprehend … this affects their skills in performing basic health education tasks, such as assessment.” Another instructor (15/FL/NS/M/PHI) stated, “if I speak in English and staff are Saudi nurses speaking Arabic, what is the use? If I do not understand, I will not follow what is being taught to me''. Another supervisor (11/ML/NS/M) stated, “If I cannot evaluate what the staff nurses are telling the patient

I cannot evaluate them.” Another supervisor 6/ml/ns/m/ins) said, “I saw Saudi nurses

providing health education but I cannot validate if it’s correct and adequate or not

because they speak in Arabic.'' Therefore, this language inconsistency in nursing

education is a real factor that affects learning, nurses’ performance and the evaluation of health education provided; and hence, nursing education has to ensure that such factors are well managed for better practice in health education. This will be examined in detail in the discussion chapter.

6.3.2.2.2 The quality of continuous medical education in health education (post registration)

Another factor affecting the health education given by hospital nurses is the quality of continuous nursing training/ education in health education on post-registration nurse education programmes. In addition, the previous quantitative data findings indicated the lack of patient education in clinical nursing programmes.

The findings reflect a gap between staff nurses and nurses managers over the quality of continues nursing education of health education. The nurse managers believe there is good training in health education as part of staff development program, as mentioned by three participants. The supervisor (16/FL/NS/M/SUP) stated that ''we have good health education training''. This claim was supported by one staff nurse (7/FL/S/ST) who said ''There is good support in training.''

On the other hand, opposing the nurse mangers’ positive perception, the findings indicate that the staff nurses have negative perceptions over the quality of the provided education. The majority of the participants believe the opposite and reported ineffective and insufficient specialized nursing training in health education once student nurses have been appointed to a post. This is reported by majority of participants staff nurses (four out of six) and two nurse managers, especially by Saudi staff nurses who believe it to be a factor affecting their performance and confidence in their practice. A supervisor (5/FL/S/M/ED) stated, “There is no specialized training in health education”. Another staff nurse (8/FL/S/ST/NW) confirmed that, saying “absolutely no training, and even the last provided training was ineffective”. Another staff nurse (9/FL/S/ST/NW) stated, “The orientation phase, which is the most important period for nurse training, was just explanation, no chances to do thing

practically and health education was omitted, which affects us now.” Therefore, the

quality or the adequacy of continuous education in health education is not clearly based on this gap; but what is clear is that staff nurses are dissatisfied with the continuous medical education in education provided. The theory-gap problem in nurses’ education is considered in the discussion chapter.

Therefore, the summary of findings about the education-related objective has two main components. First, nurses are in need of comprehensive training, this has to include many health-education skills, including: communication, active listening, problem- solving, coordination, social interaction and perceptiveness, the appropriate selection of learning strategies, time management and critical thinking. Also, nurses are required to learn several subjects of knowledge, including: knowledge of English and Arabic, basic knowledge of sociology and culture, knowledge about means of communication, knowledge of education/ instruction/ teaching, basic knowledge about administration and management, basic knowledge about human psychology and counselling.

In addition, comparing the survey findings with the interview findings, especially about the quality of health-education training, it indicates that there is clear a gap between nurse managers and staff satisfaction concerning the quality of the education provided. That actually refers to the poor management of nurses’ education/ training in health education in Saudi hospitals; especially the following section is about how barriers to health education validate the presence of several administration-related problems that affect the management of nursing training in health education.