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MALAYSIAN NURSES MOTIVATION TO STUDY ON TRANSNATIONAL HIGHER EDUCATION PROGRAMMES

Volume-7, Issue-2, 2016, Pages 34 - 41

Nirmala (Mala) Arunasalam

School of Health and Social Work, University of Hertfordshire, UK

Abstract :

Aim: To identify factors that motivated Malaysian nurses to study on one Australian and two UK Transnational Higher Education (TNHE) post-registration top-up nursing degree programmes.

Background: British and Australian University Schools of Nursing have capitalised on the prestige of their nurse education programmes to improve their profile through collaborative links with Malaysia. The lack of part-time programmes for nurses to upgrade their diploma qualifications to degree level has led Malaysia to embrace the TNHE post-registration top-up nursing degree programmes. Previous studies indicated that nurses' motivations to study were for personal and professional growth, to improve practice and to give quality care to patients.

Methods: In using hermeneutic phenomenology and the ethnographic principle of cultural interpretation, semi-structured interviews were conducted in Bahasa Malaysia (Malaysian language) and English with eighteen Malaysian nurses. The sample group were selected via convenience and snowball sampling methods. Interview data was analysed using thematic analysis.

Findings: Nurses were motivated to obtain the high status of the western degree, the financial incentives and enhanced opportunities for promotion; basically for individualistic and extrinsic reasons. The findings will help to inform the Malaysian Nursing Board, Ministry of Health and Higher Education and all engaged in international collaboration and higher education, including all TNHE programmes delivered in Malaysia, and in other South East Asian countries.

Keywords : Malaysian nurses, motivation, transnational higher education, post-registration nursing

Introduction :

Internationally, the current and pertinent trend in nurse education is the shift from diploma to degree level to ensure a well-educated nursing workforce for the delivery of quality patient care. This shift has been influenced by socio-economic factors, ongoing developments in healthcare and professional nursing issues. Significant changes in healthcare worldwide have also led to qualification escalation to ensure that respect is accorded to nurses equal to that of the other professionals (International Council of Nurses (ICN), 2008; Malaysian Nursing Board (MNB), 2008; Australian Nursing and Midwifery Council (ANMC), 2009; Nursing and Midwifery Council (NM C), 2011).

In view of this, some Australian and British University Schools of Nursing are capitalising on their positive reputations and pioneering professional developments in nurse education to develop collaborative links with Malaysia. The Ministry of Higher Education (MOHE, 2003) and the MNB (2008) recognised the need for nursing to become the degree for basic qualification and that there was a lack of part-time courses to upgrade the diploma qualifications to degree level. This led the MNB to allow private colleges linked to private hospitals, private Higher Education Institutions (HEis) and public universities to collaborate with Australian and UK HEis to deliver TNHE post-registration top-up nursing degree programmes. The Code of Good Practice in the Provision of Transnational Education of United Nations Educational, Scientific and Cultural Organization (UNESCO)/Council of Europe (2000:2) defines TNHE as "all types of higher education study programmes or set of courses of study, or educational services ... in which the learners are located in a country different from the one where the awarding institution is based". The focus of this article is the factors that motivated Malaysian nurses to study at Australian and UK TNHE post-registration top-up nursing degree programmes.

These TNHE post-registration top-up nursing degree programmes are delivered usually over two years by western 'flying faculty academics' in Malaysia. They are bridging programmes that allow diploma trained nurses to upgrade their 240 credits to a degree level qualification of 360 credits (MNB, 2007; ANMAC, 2010; NMC, 2011). This is achieved via a number of modules or credits, often 15 credits or 30 credits through face-to-face and/or distance teaching and learning.

Contextual Framework

Transnational Higher Education

Socio-economic factors have led to reduce government funding per student, vast growth in student numbers and the blurring of the university-polytechnic divide (Sugimoto, 2006; Leask, 2008). This also changed the focus of many HEis, including in the UK and Australia, towards economic and political market expansion, global recognition and the raising of international profile. The shift of focus of internationalisation by some western HEis has led to attempts to capitalise on their positive status and pioneering professional nursing practice and development.

Malaysia appears to assume that TNHE provision brings with it heightened status, international quality standards and expertise (Middlehurst & Woodfield, 2004; Morshidi, 2006). The difficulty, is that western internationalisation prioritises economic and market expansion while raising international profiles which Bone, 2009, Altbach & Knight, 2007) believe may override the need or ability to provide excellence in foreign teaching and learning.

Both Chiu (2005) and Birks (2005) stressed that with a limitation to the flexible off-campus or part-time study for working adults (lifelong learning) in Malaysia, many healthcare employers and trained nurses have opted for TNHE programmes for the upgradation from diploma to degree conversion. It is believed that TNHE provision is mainly a commercial exchange rather than an integration of international social, cultural and educational endeavour that motivates Malaysian nurses to study TNHE programmes. These TNHE programmes do not bridge the four fundamental gaps that Knight (2004) states is important i.e. language, culture, geography and history.

TNHE post-registration nursing degree programmes

The TNHE post-registration top-up nursing degree programmes delivered in Malaysia has the permission and/or the approval of the Malaysian Nursing Board. As a result, some private colleges linked to private hospitals, private Higher Education Institutions and public universities collaborate with Australian and UK HE Is to promote these programmes. The private colleges linked to private hospitals, provide these programmes as part of their in-service training or as four stand-alone modules. These in-service programmes do not require Malaysian Qualifications Agency (MQA) approval, which is only sought when these programmes are marketed as a Degree programme (MQA, 2009). In relation to this study, some participants were in programmes provided by their employers that did not require MQA approval. Others, chose to study with private Higher Education Institutions that partnered with public universities and collaborated with Australian and UK HEis as they had accreditation approvals. However, these nurses had to fund their own studies. The TNHE University chosen was either selected by their employer or was their preference. It was based on the cost, type of modules or degree they wished to acquire. The conceptual and theoretical materials taught in TNHE programmes met the needs of the MNB and employers.

TNHE post-registration top-up nursing degrees are bridging programmes that enable a diploma (240 credits) to be upgraded to degree level (360 credits) (NMC, 2011; ANMAC, 2010; MNB, 2007). This is achieved through a number of modules, usually two 15 credit modules (taught over a week each) or 30 credit modules (taught over two weeks). These are delivered by 'flying faculty academics' or by distance learning. To undertake the TNHE pathway or any stand-alone modules, nurses must have prior registration with the MNB, a Diploma in Nursing or the ability to provide alternative evidence (MORE, 2007-2010).

Malaysian nurses who complete the TNHE degree programme attain the academic award. This does not warrant registration to practise in the UK by the UK Nursing and Midwifery Council or in Australia by the Australian Nursing and Midwifery Council as they do not meet the UK and Australian professional bodies standard: this is because the programme content is 100% theory and lacks a practice component.

Motivation

In recognising that internationally, the trend in nurse education had shifted from diploma to degree level, the Malaysian MORE, MNB and Ministry of Health recognised the need for nursing degree to become the basic qualification. To encourage qualified nurses to upgrade their hospital-based diploma to degree, the Malaysian Ministry of Health started to off er a monthly graduate allowance of RM$400 as an incentive. In 2008, in tandem with this policy call, Continuous Professional Education (CPE) was enforced by the MNB as a criterion for annual re-license.

Studies in the UK, Australia and Malaysia for post-registration top-up degree programmes have been considered from a multifaceted and inter-related range of perspectives (Boore,1996; Dowswell, Hewison & Hinds, 1998; Pelletier et al., 1998; Delaney & Piscopo, 2004; Chiu, 2006; Birks, Chapman & Francis, 2009). Consistent with UK findings, Boore's (1996) study revealed that 80% of nurses were motivated by the course as it would help to improve practice and had the potential to develop their competence, whilst only 20% were inspired by the opportunity for promotion. In contrast, Dowswell et. al., (1998) study indicated that nurses, midwives and health visitors felt personal (intrinsic) motivation, including the desire for academic stimulation and life-long learning. Professional (extrinsic) motivation involved career progression, work environment pressures, and the need to support junior colleagues and student nurses. Another UK study by Hardwick and Jordan (2002) showed that nurses were driven by their professional development needs of research, Information Technology and inter-disciplinary team working.

Supporting Australian studies, Chaboyer and Retsas (1996) evaluated a Tertiary Critical Care course where nurses believed the course increased their opportunity for promotion. According to Pelletieretal's. (1998), study in Australia indicated that motivating factors were job satisfaction or personal reasons (42%), increased professional status (22%) and promotion (17%). A survey of 101 practising nurses in Australia (Delaney & Piscopo, 2004) showed personal and professional growth as reasons to obtain a degree. A raised level of professionalism was identified but was outweighed by personal satisfaction, improved knowledge and self-image and feelings of achievement.

In Malaysia, a study by Chiu (2005), of an Australian TNHE post-registration nursing degree programme that included a practice component with nurses spending four weeks in an Australian clinical setting, revealed that nurses' aspirations were for personal and professional growth and a short residential block experience at the host university campus. The degree was recognised as key to gain knowledge and achieving professional advancement, improving practice and gaining higher qualifications and professional status. Mainly, the professional development arising from international experience was reported to contribute to a deeper understanding of nursing issues, as the Australian-taught theory was directly relevant to international experience.

Another study by Birks (2005) of a UK TNHE post-registration Nursing Degree programme with only a theoretical component, showed nurses were motivated to enhance their knowledge, improve personally and professionally to implement learning in practice. A recent study by Chong et al., (2011) reviewed the motives for nurses attending local post-registration degree programmes. The study showed that they were keen to give quality care to patients and update their knowledge to achieve higher professional status.

Research Methodology :

Research Design

Hermeneutic Phenomenology was considered as it was a people-centered approach that involved identification of nurses' motivations to study, supported self-reflexivity and would enable the researcher to be part of the research process. This was to be followed-up with the ethnographic principle of culturally related interpretation of the insider's perspective of their reality and the outsider's understanding of the phenomena (Geertz, 1973;Pike, 1967).

Methodology

The qualitative approach was selected as it enables the researcher to hear the participants' voices and to probe in depth in an attempt to really understand their perspectives. This is confirmed by Creswell (2007: 161) who asserts that qualitative research uses"an investigative process where the researcher gradually makes sense of a social phenomenon by contrasting, comparing, replicating, cataloguing and classifying the object of study".

Sample Group

Initially, six participants were recruited from a UK university via convenience sampling whilst the researcher was still in the UK. In Malaysia, whilst arranging interviews with the six volunteers, five nurses who had studied with other TNHE universities showed interest in being part of this study. This led to twelve other nurses being recruited via snowball sampling from an Australian university and another UK university. All eighteen participants had completed their TNHE post-registration top-up nursing degree programme.

Instrument

Semi-structured interviews using an interview guide were carried out in both Bahasa Malaysia (Malaysian language) and English with the eighteen Malaysian nurses (six from each university) and thematic trends, similarities and data saturation emerged. An interview guide was developed to allow the same questions to be used while in conversation for each interview. In addition, a demographic survey questionnaire was constructed to reveal a snapshot of collective details and to complement the semi-structured interviews in a meaningful way.

Ethical Considerations

Formal written approval was given by the researcher's university Research Ethics Committee. The key principles from the British Education Research Association (BERA), (2011) advice about ethics were also acknowledged.

Analysis

The analysis of data from the transcripts was also carried out in both Bahasa Malaysia and English using Benner's (1994) hermeneutic analysis. To enable meaning and experiences to be extracted from the interview data and also to determine the expression, the hermeneutic phenomenological process advised by van Manen (1990) was used for the analysis and interpretation of participants' experiences.

Findings

The views of the eighteen Malaysian nurses about their motivation to study on these programmes provide the reader with the reality of their TNHE experiences. All participants had views similar to that of interviewee 013: "My ambition to do degree" and interviewee 012: "standard isn't it western degree. " Still others thought of a western degree as prestigious, as suggested by interviewee 010: "UK, I always find higher quality. " All, like interviewee 018, verbalised: "I want RM$400 monthly allowance". These features were disclosed as an incentive.

The interview data confirms the assumption of status accorded to western education. However, it is in conflict with Chong et al., (2011) findings where Malaysian nurses' motivation to participate in Degree programmes was to update knowledge and improve skills in order to raise their professional status and to provide quality patient care.

Employers determined the type of TNHE programmes offered that will be offered for their nurses, i.e. twelve nurses in this study. It appears that in choosing the programmes, employers had failed to recognise the pertinence of a practice component in parallel to TNHE theory. The reasons nurses disclosed for choosing these programmes were the attraction of an overseas degree, paid fees, study leave and free accommodation close to the study site during the teaching time-frame. Six nurses also had the additional benefit of English Language tutors to enable them to obtain the International English Language Testing System qualification and the support of a local coordinator throughout their programme of study. However, the six nurses who self-funded their training, stated that they purposefully chose TNHE programmes with only a theoretical component. Post-course, they realised: "Culture is different, difficult to understand. Understanding of theory is different when you can apply in practice. Must have practice, this is nursing not accounting"(Int: 014).

Another interviewee 001 who studied with the Australian TNHE programme stated: " ... our employer takes it not for quality, just [accept] for ranking and qualifications. To advertise all nurses, have degree. " Her view confirms that international partners may be selected to gain prestige and ranking (Williams, 2012). Some nurses also stated they were disappointed by their academic achievement, as it did not accurately reflect their knowledge, understanding and ability to consolidate and apply their learning in practice. This is illustrated by self-funded interviewee 017:

"If you ask me about [how to apply] research [ at work], sorry I am not able to tell you, even after doing research project, because my understanding is not good enough. So I feel embarrassed in that way. I even now thought of going/or short research methodology courses in Malaysia. You have to pay quite a lot of money and you go like one week course but again what is the point of taking it from this TNHE University and now I have to pay again. It's awaste!

Certain nurses from the UK University who were sponsored by their employer were dissatisfied: "We didn't do research project. I know, other UK university did research project for honours. Our honours degree like Australia, four modules only" (Int: 012). These nurses appeared resentful that their learning did not reflect the knowledge required to achieve the Honours title. Instead they felt it was similar to a general degree rather than reflecting a higher level Honours degree. Hence, it was perceived to be of a lower status compared to the other UK University.

All participants accepted provision of TNHE programmes in Malaysia; as interviewee 013 said: ''provided an opportunity to obtain a degree" but some, like interviewee 008, stated: "... want the degree to learn " and stressed the need for quality programmes rather than those that were - as interviewee 017 said - " ... two weeks, assignment based, I give you certificate degree and finish”. Others, " ... just want the paperwork”. Six nurses said that they were pleased when one UK academic, on their first day and whilst introducing the programme, said: "don't worry end of the day you will get it, get a degree! "(Int: 002). Interviewee 001 from another TNHE university stated:

"Personally, I think everyone don't mind because they still get their degree and RM$400 allowance. Knowing and not knowing the depth of degree studies is not important, so long as they got the rank and the qualification.

The issues raised from the literature review for this research were the potential differences in expectations and assumption in the teaching and learning environment and the gap between Malaysian and Western pedagogic and professional values. Based on these differences, there were questions about whether the degree was primarily for "instrumental'' reasons (Furnham, 1987) or individualistic reasons which were motivated by intrinsic or extrinsic factors. The answer to that question is a resounding "yes" to individualistic reasons and to extrinsic factors. The nurses' motivation to study in TNHE programmes was mainly influenced by their desire to get a high status western degree, financial incentives and promotion; basically individualistic and extrinsic reasons rather than embracing the learning to improve patient care (Arunasalam, 2013). In their personal quest to achieve the degree, they indirectly met the Ministry of Health's, MNB's, Vision 2020 and the objectives of the employers' was satisfied to upgrade Malaysia's nurses to graduate status.

On completion of the degree, it was evident from their views that irrespective of whether learning had taken place or acquisition of theoretical knowledge that was applicable in the clinical practice, all acknowledged they had attained a western degree, graduate status, financial reward and enhanced career prospects. Yet again, this confirms that their degrees were undertaken primarily for individualistic and extrinsic reasons: it was not for collective purposes of transforming thinking or mindsets, nor changing practice for public good, or for empathic grounding, as is usually assumed in nursing.

The findings illuminate western TNHE as delivered in Malaysia, from Malaysian nurses' perspectives. It is not quantifiable but they enable a new synthesis or a third view to emerge, one that was hidden or not previously revealed.

The nurses' initial transitional experience was a painful and challenging process as they had difficulty in comprehending and had to fast-track their learning in an assessment-focused mode with less support than expected. It also had transformational effects on their relationships with aspects of learning and clinical practice. Exposure to the programme and the desire to succeed, for all the differences and nurse-reported shortcomings, does appear to have encouraged the nurses to overcome cultural and learning shock to make necessary adjustments with effective coping strategies to meet the assessment criteria and achieve their degrees successfully.

Conclusion :

Partnerships and collaboration appear to be always advantageous.  This research provided a platform for Malaysian nurses to voice their perspectives about their motivation to study on TNHE post-registration nursing top-up degree programmes. The interview data using the verbatim extracts of nurses' unique voices confirms the assumption of high status accorded to western education, financial incentives and promotion; basically for individualistic and extrinsic reasons. However, this is in conflict with Chong et. al., (2011) findings where Malaysian nurses' motivation to participate in local top-up degree programmes was to update knowledge and improve skills in order to raise their professional status and to provide quality patient care. It is worth noting that improving the status of the nurses and the nursing profession may not necessarily equate to improving the standard of patient care, unless implementation in provision of patient care is directly addressed in its own right. The data is relevant to those engaged in international collaboration and higher education, including other professions, and all TNHE programmes delivered in Malaysia, and in other South East Asian countries.

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