Cross-sectional survey on nurses' views, attitudes and concerns about appraisal and revalidation in improving clinical performances

Master's Thesis , 2010 , 73 Pages , Grade: Pass

Nursing Science - Nursing Management

Research Focus - The aim of this dissertation is to investigate the views, attitudes and concerns of nurses about the role of revalidation in improving clinical performances.

Methods - The ethical approval was obtained from the Health and Social Services Ethics Committee of Jersey. The research study involved trained nurses working at the General Hospital and two Nursing homes within Health and Social Services of Jersey. The participants were selected through purposive sampling due to their particular characteristics associated with the research aim. A mixed methods approach, using questionnaires and focus group discussion, was taken to collect data with a view to obtaining more information that might be undetected in the questionnaire. Six participants were involved in the focus group discussion and 100 self-administered questionnaires were distributed to the nurses within the selected settings.

Results: The response rate was 55%. 92.7% of the respondents believed that appraisal was a confidential process and 56.4% agreed that appraisal and revalidation were the same. 49.1% of the respondents were in favour of appraisal compared to 43.6% in favour of revalidation. 67.6% believed that revalidation could improve their clinical performances whilst 38.6% believed that performance review and appraisal had no effects on their clinical performances.

Conclusion - This research study has shown that there are still divided opinions about appraisal and revalidation. Some people viewed appraisal as only theoretical with no practical evidence in improving clinical performances. The study also discovered that some nurses did not want patients and public involvement in their revalidation process. There was also lack of understanding between assessment, appraisal and revalidation by some nurses. The response rate and sampling methods might reduce the confidence to claim that this study had achieved the representative views of the broader nursing profession at the Health and Social Services of States of Jersey. However, the research argues for a need to research into the views and opinions of nurses towards appraisal and revalidation that could represent the broader views of the nursing profession and also attitudes of nurses towards patients and public involvement in appraisal and revalidation

CONTENTS

Acknowledgments

Dedication

Abstract

Aim

Introduction

Background information

Literature Review
- What is Appraisal?
- Types of Appraisal
- What is Revalidation
- Revalidation and Re-certification of nurses in the UK
- Revalidation and Re-certification of other Professions in UK
- An overview
- Why do we need Appraisal and Revalidation?
- Conclusions drawn from literature review

Research Design
- Methodology
- Research Question
- Ethical Issue
- Methods
- Problems Anticipated and How They Were Overcome
- Data Analysis

Results

Discussions

Conclusions and Recommendations

Referenc

Appendic
a. Ethical approval email by the secretary
b. Circular to ward managers
c. Invitation to participate in the study
d. Research questionnaire
e. Research information sheet
f. Consent form

ACKNOWLEDGEMENTS

I am truly indebted and thankful to my supervisor, Professor Dr. David Blaney, for the support and guidance he has shown to me throughout my dissertation writing. I am also thankful to the Director of Nursing and Clinical Governance; Head of Education, Training and Development Unit (Julie Mesny) and Head of Risk Management, Tarina Le Duc, for their valuable suggestions and support they offered to me during the conduction of this research study. I am sure it would have been very difficult without their support.

I would like to thank the Health and Social Services Department for reimbursing 80% of the cost of this dissertation research study. I am obliged to my present (Lorna Smith) and former managers and to many of my colleagues for their moral support; and also to all those who participated in this research study. My sincere appreciation to the Health and Social Services Ethics Committee for approving this research study and to the librarian at the Jersey General Hospital for his patience and support during this dissertation writing.

I am grateful to Mr Simon Carr, former Academic Director of Department of Health, Nursing & Midwifery and Professional & Community Education, University of West of Scotland, for his words of encouragement which enticed me to pursue both my undergraduate and postgraduate degrees.

Finally, I owe sincere and earnest thankfulness to my family with much love to our son, Sainey Duta Keita.

DEDICATION

This academic achievement is dedicated to my late beloved father and aunt for their foresight and inspirational characters, which will be remembered forever.

ABSTRACT

Research Focus - The aim of this dissertation is to investigate the views, attitudes and concerns of nurses about the role of appraisal and revalidation in improving clinical performances. The introduction of appraisal and revalidation for doctors in the UK and the possible introduction of it by Nursing and Midwifery in the near future make the timely need for this research.

Methods – The Ethical approval was obtained from the Health and Social Services Ethics Committee. This research study involved trained nurses working at The General Hospital and two Nursing homes within Health and Social Services of States of Jersey. The participants were selected through purposive sampling due to their particular characteristics associated with the research aim. A mixed methods approach, using questionnaires and focus group discussion, was taken to collect data with a view to obtain more information that might be undetected in the questionnaire. Six participants were involved in the focus group discussion and 100 self-administered questionnaires were distributed to the nurses within the selected settings.

Results – The response rate was 55%. 92.7% of the respondents believed that appraisal was a confidential process and 56.4% agreed that appraisal and revalidation were the same. 49.1% of the respondents were in favour of appraisal compared to 43.6% in favour of revalidation. 67.6% believed that revalidation could improve their clinical performances whilst 38.6% believed that performance review and appraisal had no effects on their clinical performances.

Conclusions - This research study has shown that there are still divided opinions about appraisal and revalidation. Some people viewed appraisal as only theoretical with no practical evidence in improving clinical performances; and the study also discovered that some nurses did not want patients and public involvement in their revalidation process. There was also a lack of understanding between assessment, appraisal and revalidation by some nurses. The main conclusions drawn from this study were that there were different views and opinions about revalidations. The response rate and sampling methods might reduce the confidence to claim that this study had achieved the representative views of the broader nursing profession at the Health and Social Services of States of Jersey.

This research argues for a need to research into the views and opinions of nurses towards appraisal and revalidation that could represent the broader views of the nursing profession and also to research into the views and attitudes of nurses towards patients and public involvement in appraisal and revalidation.

AIM

The overall aim of this study is to investigate the views, attitudes and concerns of nurses in relation to appraisal and revalidation and the effects it has on their clinical performances.

INTRODUCTION

This research project is aimed at investigating the views, attitudes and concerns of nurses about the role of appraisal and revalidation in improving their clinical performances. The background information provides a brief description of the establishment of the regulatory body responsible for nursing profession in the UK. It also critically reviews previous and current policies on appraisal, revalidation and recertification of nursing profession in the UK in reaction to government White Paper “Trust, Assurance and Safety: the Regulation of Healthcare Professionals in the 21st Century” (NMC, 2010). The background information also sets out in detail about the research focus/objectives.

The literature review describes the definition of appraisal, the types of appraisal and definition of revalidation; and the reasons for revalidation and appraisal. It also explains in detail about revalidation and recertification of other healthcare professions in the UK.

This research study uses cross-sectional survey design and the methods involved distribution of 100 questionnaires and focus group discussions, involving nurses working within Health and Social Services of States of Jersey. The method of this study involved analysing participant’s information and developing descriptive statistics, using percentages and tabular forms.

There are final discussions, conclusions and recommendations from the study.

BACKGROUND INFORMATION

Appraisal is not an uncommon word to the industrial world and some employers use performance appraisal to gauge the competence of their employees. It is believed that appraisal and revalidation are now going to be the tools to assess the competence of nurses, doctors and other healthcare professionals. The General Medical Council (GMC) has already incorporated an appraisal system in the revalidation process of medical doctors, but there is still no formal introduction of appraisal system in the revalidation process of nurses. The public expect health professionals to undergo revalidation of their registration annually (NMC circular 10, 2008). Revalidation is not a new word in nursing; and Nursing and Midwifery Council has been using a system called post registration education and practice (PREP) to revalidate nurses. This system of revalidation is quite open to critics and The Bristol inquiry has recommended external assessment as part of revalidation for other professionals, including nurses (Bristol Royal Infirmary Inquiry, 2001). However, non-medical regulatory bodies governing non-medical professions are allowed to set their system of revalidation based upon the degree of risk their practice poses to patients (DoH, 2008).

According to NMC (2010) and RCN (2007) in February 2007, the ‘White Paper’ on regulation ‘Trust, Assurance and Safety – the Regulation of Healthcare Professionals in the 21st Century’ was published along with government response to the Shipman and other inquiries ‘ Safeguarding Patients and Learning from Tragedy’. The publication of this ‘White Paper’ is a clear manifestation that there was a need for revalidation of healthcare professionals to protect the public and that trust alone was not guaranteed enough to demonstrate one’s fitness to practice (NMC 2008; NMC circular 10, 2008). Revalidation for nurses in the near future will require, amongst other things, showing evidence from appraisals; and in July 2009, the NMC appointed a researcher partner, Matrix Insight Ltd, to ‘undertake research into outcomes from appraisals, staff development systems, clinical audit, nursing metrics and output based CPD on their behalf to develop a model of revalidation (NMC News, 2009).

The Matrix Insight Ltd will also conduct a study to determine if it is possible to introduce a validation point for nurses and midwives whereby they will have to show they have skills in leadership, teaching and management through a period of mandatory preceptorship.

Recently NMC has launched a survey asking nurses about their views on current appraisal processes to develop standards and procedures for introduction of a system of revalidation whereby nurses and midwives can provide evidence of their continuing fitness to practice (Nursing in Practice, 2009; NMC News, 2008).

Professor Tony Hazell, charged with the rehabilitation of the NMC, expressed concern with government’s determination to impose revalidation on the health professions, saying he was “not convinced it was necessary” – although he acknowledged that the debate “needed to be had” (Nursing Times, 2008). According to Nursing Times (2008, p1) while Professor Hazell emphasised expressing a personal view, he said : ‘we’ve got a long way to go in the debate, before we come to any conclusions. My own view is that we need to ask questions like “what will revalidation achieve, what is the risk out there’ and, very importantly, “what would the cost be?” However, there are still concerns whether revalidation can detect poor performers (Zwanenberg 2004)

It is in view of these different perceptions and opinions held by different healthcare professionals that this research will investigate the views, attitudes and concerns of nurses about appraisal and revalidation and its effect on their clinical performance since the overall aim of revalidation is to improve clinical performance.

THE LITERATURE REVIEW

What is appraisal?

The word appraisal may mean different things to different people, but Dangerfield (2003, p1) described appraisal as ‘an ongoing, two-way process involving reflection on an individual’s performance, identification of education needs and planning for personal development’. NHS Appraisal (2004) stated that appraisal is not about performance management but identification of developmental needs.

Conlon (2003a) is with a view that appraisal helps individuals to reflect on their performances to identify their strengths and weaknesses. Conlon (2003a) and Davies et al (2005) also narrated that appraisal helps professionals to reflect on their experiences which create more new ideas for them to move on the learning cycle. Appraisal has become so much controversial and disputable that some organisations have renamed it as performance review or work planning review in order to lessen its assessment element (Redshaw, 2008)

Appraisal and assessment are sometimes confused with each other but there is different between them. Assessment is about performance measurement whilst appraisal is all about identification of professional needs and it is a confidential and supportive process (Davies et al, 2005).

There are different types of appraisals, but appraisal itself may involve appraisal, assessment and performance management as described in box 1.

Abbildung in dieser Leseprobe nicht enthalten

Every organisation needs commitment from its employers to be successful and so is for any appraisal system in any organisation. The organisations need to involve both their junior and senior staff in planning and implementing the appraisal systems in order to be successful. It is a common saying that people like to be more active in what they have created and by involving them would make them more committed.

Conlon (2003a) also stated that for appraisal to flourish, ‘responsibilities must be accepted at personal, local, and national levels’ and evidence has shown that many appraisal systems have collapsed due to their top-down approach (Dangerfield, 2003).

The different types of appraisal

Educational appraisal is about meeting the learning needs of the appraisee which involves evidence of performances both objective and subjective. NHS appraisal (2007) described that a fair assessment of the trainee cannot be made by a trainer who has not regularly, honestly and openly appraised that trainee in relation to all the positive and negative aspects of his/her performance and progress.

Appraisal is intended to be part of the educational process and according to Gatrell & White (2001); Kolb et al (1984) proposed a model of learning which is useful when considering the developmental role of appraisal (Figure 1).

Abbildung in dieser Leseprobe nicht enthalten

Figure 1 Kolb learning cycle (adapted from Kaufman & Mann, 2007

Concrete experience is gained through interaction with others and Gatrell & White (2001) described it as being involved in experiences and dealing with immediate human situations in a personal way. It emphasises feeling as opposed to thinking, and is about present reality as opposed to theories and models.

Reflective observation focuses on the meaning of situations and ideas and their implications, and emphasises understanding as opposed to practical application.

Abstract conceptualisation focuses on logic, ideas and concepts. It emphasises thinking as opposed to feeling and is about building general theories rather than intuitive understanding.

Active experimentation is all about practical applications – what works, as opposed to what is absolute truth. There is always some risk link to this stage in the learning process, and it is about getting things accomplished. Gatrell & White (2001) mentioned that Kolb et al. suggested that learning takes place when the learner follows the full cycle. Gatrel & White (2001) argued that a well conducted appraisal meeting will provide an opportunity for the appraisee to gain important new concrete experience, through interaction with a senior colleague whose opinion is important to him/her; and also the appraiser should help the appraisee to reflect on experience, and helps him/her to acquire and develop understanding of new concepts.

Peer appraisal is about evaluating the performance of the employee by work colleagues rather than by the manager (E-Learning community on Management, 2007). According to Conlon (2003a) peer appraisal involves appraisal of performance, personal or professional which involves reflection and is formative, developmental and confidential. Peer appraisal gives the appraisee and the appraiser the opportunity to gather information/opinions from different people which minimise the risk of biasness/subjectivity. One of the disadvantages of peer appraisal is that it consumes a lot of time and prone the appraiser to criticism from peers, but E-Learning Community of Management (2007) argued that this advantage should not be an obstacle for any organisation to develop a peer appraisal system.

Performance appraisal is a major issue with health care workers as it is seen as a form of revalidation for licensing or promotion (Dangerfield, 2003). Although performance appraisals are necessary for staff management, E-Learning Community of Management (2007) argued that staff in certain organisations do not like performance appraisal and sometimes refer to it as a ‘blocking sessions’. However, the advantages of performance appraisal cannot be overemphasised because it helps the appraiser to link his/her objectives to that of the organisation and gives opportunity to him/her to discuss issues that could bring improvement to the organisation. Coens and Jenkins (2001) narrated that the majority of the appraisal systems do not work well and there is no hard evidence that it promotes motivation of staff or improves staff performances.

Many writers on appraisal, including Bacal (2008a) stated that performance appraisal is widely misused by many managers which contributed to it being hated by staff and costing a lot of money. Nickols (2000) estimated that the performance appraisal system of a company could cost between $1,945 and $2000 per employee.

However, there are two sides to any appraisal such as judgement and development (future-orientated) and according to E-Learning Community of Management (2007), performance appraisal should be seen as positive exercises and the process should be the platform for development and motivation. Heathfield (2010) argued that performance appraisal doesn’t work well and it causes psychological stress, de-motivation and pain to employee, in addition managers are uncomfortable in the judgement seat and a staff member becomes defensive when his/her performance is rated as less than the best, the manager is viewed as punitive.

Performance appraisals should not only be conducted for just job promotions or skills needed for the job, but should also address the appraiser as a person which can minimise the fear people have against it (Bacal, 2008a). Coens and Jenkins (2001) also stated that creating a compelling vision, promoting and providing interesting work, giving people freedom and choices in their work, offering people challenges and creating a climate of people working together would highly create a motivated workforce. Murphy and Margulies (2004) highlighted that using different approaches, such as peer review or 360 degree appraisal, could improve performance appraisal.

Bacal (2008b) highlighted 7 inappropriate things that employees do to impede performance appraisal:

- Focusing On The Appraisal Forms
- Not Preparing Beforehand
- Defensiveness
- Not Communicating During The Year
- Not Clarifying Enough
- Allowing One-sidedness
- Focusing On Appraisal As A Way of Getting More Money

Bacal (2008c) has outlined a few factors that managers should be aware of, so that they could be free from bias when performing performance appraisal:

- Halo Effect – the possibility to rate someone high or low in all categories because he/she is high/low in one or two areas. Evaluating someone lower is sometimes also called the “devil effect”.

- Leniency Bias – the tendency to rate higher than warranted.

- ‘Opportunity Bias – ‘ignoring the idea that opportunity (factors beyond the control of the employee) may either restrict or facilitate performance, and assign credit/blame to the employee when the true cause of the performance was opportunity’.

- False Attribution Errors – the likelihood to attribute success/failure to individual effort and ability. So credit is given for doing well and for doing less, you are blamed as your fault’.

- Central Tendency – the habit of assessing almost everyone as average.

- Regency Bias – the possibility to assess people based on most recent behaviour and ignoring the behaviour that is “older”.

360- Degree appraisal is sometimes referred to as a multi-source feedback system whereby the employee receives anonymous feedback from all the different people who work with the appraisee (Ngo, 2010). It can also be defined as an evaluation method that incorporates feedback from respondents (as illustrated in figure 2) or anyone who has worked/contact with the appraiser (Linman, 2010; West, 2002).

The 360 degree appraisal system has become more acceptable to many organisations due to the limitation of the traditional ‘top-down’ approach which became apparent as being very subjective. Thus, feedback from multiple sources gives more credit and reliability to the appraisal process.

Figure 2 360-degree feedbacks from multiple sources

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It is a common saying that two heads are better than one and therefore, using multiple sources, such as from superiors, peers, juniors and patients to appraise healthcare workers will greatly improve objectivity of the process. However, it is imperative to note that if the appraisal is not conducted properly or proper data is not collected it will cause more stress to the appraiser than improving his/her performances. 360-degree feedback is becoming very common with many organisations, but it has been argued that it cannot work well in an unfriendly organisation where employees cannot openly comment/criticise each other (Linman, 2010). It is suggested that any organisation ready to use 360 degree appraisal must be ready to provide counselling support to employees to avert any serious problems as very often open honest feedback can be very sensitive. However, for 360 degree appraisal to be more successful the tool must fit for purpose and be easy to administer and analyse; people providing feedback should be anonymous and the tool must not be used to manage staff performances. Linman (2010) also added that for any organisation to have a successful 360-degree appraisal, it must have the following attributes:

- Criticisms are seen as opportunities for improvement
- Proper framing of feedback method by management
- Assurance that feedback will be kept confidential
- Development of feedback tool based on organizational goals and values
- Feedback tool includes area for comments
- Train workers in appropriate methods to give and receive feedback
- Support feedback with back-up services or customised coaching

However, Ngo (2010) highlighted that a good 360-degree appraisal will greatly help

Employees to:

- uncover hidden lights and blind spots.
- gain a realistic view of how others perceive them.
- inspire people to take ownership of their own learning and development.
- understand how their behaviour influences both their own personal effectiveness and how they impact the smooth running of the organisation.
- support teamwork by involving team members in the development process.
- increase communication between team members.
- Increased team effectiveness.

Organisation to:

- better career development planning and implementation for employees.
- improve customer service by having customers contribute to the evaluation process.
- help with training needs analysis.

What is Revalidation?

Revalidation involves evaluating a healthcare practitioner whether he/she is fitness to practice and it entails showing regularly that you are up to date and fit to practise (Zwanenberg, 2004). Revalidation is both linked to registration for doctors and nurses where they have to demonstrate evidence of CPD to maintain their names on the register and to be eligible to continue to work as doctors or nurses. In nursing, however, nurses have to show that they are up to date with their skills and knowledge and have met the required standards of performance set by NMC to continue to work as nurses.

Baron (2008, p1) stated that revalidation is the term used in the UK to describe a “new system for ensuring healthcare professionals remain competent to practise throughout their career – meaning health professionals must periodically demonstrate their continued fitness to practise”. However, revalidation in general terms mean regular demonstration of fitness to practise by healthcare professionals through submission of evidence to individual professional regulatory bodies. In nursing, this is done every 3 years and for doctors every 5 years (Bristol Royal Infirmary Inquiry, 2001).

The revalidation process should also identify shortcomings in individual practice and enable professionals to keep their skills up to date. Revalidation involves summative assessment of one’s performance against the agreed target/standard. Assessment is about making judgement against the defined criteria (Jolly, 1997).

Revalidation and Recertification of Nurses in the UK

Nursing and Midwifery Council (NMC)

In the UK, the regulatory body responsible for nurses and midwives is NMC. The NMC was purposely set up to protect the public by Parliament and this is done by ensuring that nurses and midwives provide high standards of care to their patients and clients (Medical News Today, 2008).

The NMC is also responsible for setting educational standards, training and performance and conduct of nurses and midwives and also to ensure maintenance of these standards (NMC, 2008; Nursing and Midwifery News, 2008). The pre-registration nursing education is changing from the traditional diploma to a degree level in order to meet the recommendation made in the document ‘Fitness for Practice and Purpose’ published by the UK Central Council for Nursing, Midwifery and Health Visiting (UKCC) Post Commission Development Group in 2001 (NMC agendum 17, 2008). According to NMC (circula70, 2008) and Nursing Times (2009) this diploma programme will be changed to a degree level by September 2011 and anybody intending to register for nurse training after this date will have to take a degree course. The current diploma students will not have to change their course to degree level and current registered nurses can do further courses to top up their diploma to degree level if they wish to do so (Nursing times, 2009).

Nurses trained outside the UK and European Economic Area (ECA) and willing to register with NMC must first be registered with their home nursing regulatory body and must have at least practised for twelve months in their chosen field and they should also apply through an overseas registration route. The general public is quite critical about overseas trained nurses’ and doctors’ knowledge of English language and as a result overseas trained nurses must show that they have knowledge of English language before working in the UK and this is supported by the public consultations done by NMC for nurses in November 2003 and for midwives in October 2005 (NMC, 2010). They must have an International English Language Test Score (IELTS) of 7.0 in each category prior to making their first application (NMC, 2010). They must also undergo Overseas Nurse Programme (ONP) which is offered by few colleges and universities. The ONP offers twenty days protected learning time and six months supervised clinical practice within a recognised clinical setting (NMC, 2010). European Union (EU) nationals do not take IELTS, but those trained in non-EU countries and holding EU passports are treated as overseas applicants and should apply through the overseas registration route (NMC agendum 37, 2008; NMC, 2010).

The NMC introduced statutory requirements for periodic registration of nurses in April 1995 to ensure nurses continue to maintain their professional skills and competence (UKCC, 1995c). The NMC has now introduced a new system of appraisal which demands every registrant to do annual renewal of their registration with a view to promote best practice and burst public confidence in the profession. However, this system of appraisal has raised many eyebrows because it does not involve showing any evidence of professional knowledge and competence rather it involves only payment of registration fees.

Currently, NMC uses a revalidation scheme called post registration education and practice (PREP) and the principles underpinning PREP which requires nurses and midwives to take active responsibility in maintaining their competence through regular professional development (NMC circular 10, 2008; NMC 2009). The PREP requires nurses and midwives to meet a practice standard by signing a declaration form that they have had at least 100 days (450 hours) of working in their chosen discipline and have had five days / 35 hours of CPD in the last three years before applying for renewal (Wang, 2002). They are required to provide notification of their PREP and qualifications every three years and notify NMC of their intention to continue in practice. Nurses can use the temple developed by NMC to describe their learning activity and explain how it has been done and how the learning activity has influenced his/her work. However, there is no check and balance of these PREP documents/records and the NMC has stopped scrutinising them since 2006. Unlike GMC, NMC has still not introduced a formal appraisal system in the revalidation process of nurses, but they have set up a revalidation project which runs in four phases, such as gathering of information phase, policy development phase and the introduction and roll out phases.

Revalidation and Recertification of other Professions in the UK

Medical profession

Like the nursing profession, medical doctors are expected to develop and maintain their skills, knowledge, competence and performance up to date by attending some educational activities/programmes (Wang, 2002). The present system of professional self-regulation of the medical profession is common to many healthcare professions in the UK and this has been in practice since the establishment of the Medical Act in 1858 and the creation of the General Medical Council (GMC). It has been reported that the confidence people have in the medical profession and its self-regulation has dropped and according to Hunter et al (2005) in 1997 the GMC published its draft policy on revalidation and central to this was the proposal to introduce annual appraisal for doctors. Zwanenberg (2004) reported that GMC confirmed the introduction of revalidation for doctors in May 2001 and this was considered a historic event since the formation of self regulation of the medical profession. However, revalidation for General Practitioners in England was introduced in 2002 and a year after in Northern Ireland followed by Scotland and Wales in 2003 and 2004 respectively (Sparrow, 2008). It is anticipated that by 2005, most doctors in the UK would have gone through the appraisal process to revalidate their licence. Those revalidating their licence must show evidence that there are no concerns about their competence/fitness to practice. The government ‘White Paper’ has emphasised that appraisal should be the focal point for revalidating GPs and according to DoH (2008) the Medical Revalidation document stated that relicensing and recertification would be the main part of the revalidation of the doctors. The information obtained from the annual appraisal will form part of the relicensing process whilst standards set for specialist doctors will be part of the recertification process.

The findings of GMC consultation document on “Revalidating Doctors, Ensuring standards and Securing the future’ and The Medical Act 1983, Amendment Order 2002 lead to the publication of ‘A Licence to Practice and Revalidation’ that outlined two routes to revalidation”( GMC, 2003; cited in Rambihar, 2005, p18):

- Appraisal Route – ‘doctors choosing this route needed to demonstrate to the GMC that they had participated in appraisal in a managed environment and needed to show a folder of evidence drawn from their day to day practice and certificate from the clinical governance lead that there are no causes of concern’.
- Independent Route – ‘those choosing this route needed to demonstrate that they have adopted the principles of “Good Medical Practice” in their professional practice and have undertaken appropriate continuing professional development’.

However, the recent routes to revalidation and recertification of doctors in UK as mentioned by Sparrow (2008) are as follows:

- Undergo annual appraisal system
- Show evidence of CPD log each year
- Assessment presentation by the appraiser
- Every five years the doctors will undergo a revalidation process.

Dentists

From January 2002, The General Dental Council (GDC) has introduced a recertification programme ‘Lifelong Learning’ and as stated by Bullock et al (2003) and Wang (2002) each dentist will have do a minimum of 250 hours of CPD during a period of five years and 75 hours of this minimum hours have to be a ‘verifiable CPD’. Verifiable CPD means that the person has to attend an educational programme that is more relevant to his/her training and must be certified. Some of these courses are run by Postgraduate Dental Deans and Directors (Wang, 2002). Every 3 years each dentist has to undergo either a peer review or clinical audit of fifteen hours as part of the verifiable CPD. Postgraduate courses leading to diplomas and degrees also fall into verifiable CPD. Course attendance, journal reading and discussion with colleagues are the most frequently general CPD activities taken by dentists (Rambihar, 2005).

Unlike nursing, dentists are sometimes randomly selected to verify their verifiable CPD certificate(s) and defaulted persons could face denial for recertification if they continue to fail the requirements within a five-year period (Wang, 2002).

Pharmacists

Like other healthcare professions, pharmacists are also required to keep their knowledge and skills up to date by doing some continuing education. The regulatory body responsible for pharmacists in the UK, Royal Pharmaceutical Society of Great Britain, ensures that each pharmacist has done a minimum of thirty hours of continuing education and CPD every year to fulfil this requirement (Royal Pharmaceutical Society of Great Britain, 2003; cited in Rambihar, 2005). In the past, the requirements for CPD were ethical until 2005 when it became mandatory, incorporating the recommendations of the Shipman Inquiry (Shipman Inquiry, 2004; cited in Rambihar, 2005).

Overview

The conclusions drawn from this literature review had shown that the regulatory body of each profession has different ways on revalidation and recertification of their professionals. It has also been noted that professional self-regulation is common to all major healthcare professions, such as Doctors, nurses, dentists and pharmacists, in the UK. In the medical profession, revalidation is carried out every 5 years and the process involves undergoing annual appraisal and showing evidence of CPD log each year, whilst in other professions, such as nursing there is no formal appraisal system integrated into their revalidation process/scheme. It is only the medical profession that has integrated the appraisal system into their revalidation process. In the literature review, it appeared that there was more concern about the revalidation of the medical profession than other healthcare professions.

There are different recertification programmes for each professional body, but continuing professional development (CPD) is an essential component to all and according to Wang (2002) the statutory regulatory body for each health profession would have a common duty - to ensure that professionals on their respective registers are “fit to practise”.

Why do we need appraisal?

The theoretical underpinning appraisal has been based upon strong evidence that ‘feedback on individuals’ job performance is associated with improvements in performance and reductions in error rates across all employment sectors’ (West, 2002 p669). According to Hunter et al (2005) and Conlon (2003a and 2003b) in the UK, the confidence people have in healthcare professionals had gone down which culminated for the end of self-regulation and introduction of public input into regulation and monitoring of doctors’ performance in practice and nurses are not immune to these changes. Recent instances of poor clinical practices by few healthcare professionals, like the case of Bristol heart surgery, Hyde or Dr Harold Shipman case had all contributed to the need for an appraisal system for healthcare professionals (Conlon 2003a; Baron 2008). The government was concerned about the effect of these cases on public confidence of doctors and made proposals for change in the document, ‘Supporting doctors, protecting patients’ (DoH, 1999) . There are instances where the standard of care given to patients/clients by nurses have been questioned and the recent suspension of nurses for low standard of patient care in one NHS trust (Nursing Management, 2010a) are all testimonies why there is a need for appraisal for healthcare professionals. Recent figures have shown 13.4% (from 89,139 in 2008/2009 – 101,077 in 2009/2010) rise of complaints about healthcare services in England (Nursing Management 2010b). Due to these lapses, West (2002) reported that many organisations, including Patients’ Association have backed the idea for doctors and other healthcare professionals to have appraisals systems. However, Zwanenberg (2004) argued that appraisal may not be ‘sensitive (identify poor performance), valid (reflect actual clinical performance) or reliable (be consistent across cohorts of doctors)’

Why do we need revalidation?

It has been reported that in the past there was no revalidation for healthcare professionals to assess their competence. There was high trust for healthcare professionals once they have successfully completed their training but there were “no ‘mechanisms, whether within or outside the professions, whether from employers or bodies concerned with registration and discipline, to assess and check a professional’s competence” (Bristol Royal Infirmary Inquiry, 2001 p342). It means most of the healthcare professionals had to develop their own competence through experience and/or CPD if they are keen to do so and according to Bristol Royal Infirmary Inquiry (2001) there were no means of gauging the competence of these professionals or giving them support, leading to patients/public being unprotected. In response to the new legislation introduced in December 2002 as part of a wide ranging reform process for GMC, revalidation of all doctors in the UK was introduced in 2005.

Apart from the history of the Bristol case, the public was also very disappointed about the system failures which they entrusted and also the failure of service providers to change with time and all these lapses had reduced public confidence in healthcare, leading to the rise of the government's concern about the under-performing doctors.

Although there are concerns about the effectiveness of revalidation, there is evidence that revalidation can improve performance (West (2002). However, Zwanenberg (2004) outlined three overriding themes with regard to the purpose of revalidation:

- Securing public trust,
- Promoting CPD,
- Identifying under-performing healthcare professionals.

Bristol Royal Infirmary Inquiry (2001) highlighted that the public was entitled to protection and the introduction of a revalidation scheme for healthcare professionals will give great assurance to the general public. In a survey conducted by GMC, Broad (2010) stated that seven out of ten members of the public said that they would have more confidence in their doctor once revalidation is implemented. However, Elwyn (2005) stated that Professor Pringle (former chairman of the Council of the Royal College of General Practitioners) argued that to truly protect the public, “revalidation had to address poor performance as well as provide a mechanism for the episodic assessment of all doctors; and failure to address the need to weed out those doctors who are ‘not fit’ to practice is to retract into paternalism; a protective professional attitude that he argues is not sustainable. It is, he contends, a serious problem if the GMC continues to hold the line that revalidation is about confirming safe practice while denying an equal parallel responsibility to detect and excise poor performance” (Elwyn, 2005 p562).

Conclusions drawn from literature review

In the literature review, it became clear that appraisal and revalidation are not the same and the different types of appraisal had been stated. Appraisal is regarded as a strong indicator of a healthcare professional’s fitness to practise. The main reasons for the need for appraisal and revalidation had been stated. There were also arguments that performance appraisals impede genuine feedback and there was no solid evidence that it motivates people or leads to meaningful improvement (Coens and Jenkins, 2001). However, it was stated in the literature that there was much indirect research evidence that feedback on an individual's job performance was associated with improvements in performance (Davies et al 2005; West, 2007). There is also an existence of confusion and uneasiness about whether revalidation is intended to detect poor performers and its link with appraisal (Zwanenberg, 2004). The literature review has shown that there are still different opinions/perceptions about revalidation and appraisal and their impact on clinical performances; and there was no location of systematic studies of nurses’ views and attitudes on formal appraisal and revalidation.

This research is intended to investigate the views, attitudes and concerns of nurses about the role of appraisal and revalidation in improving clinical performances.

RESEARCH DESIGN

Methodology

This is precisely the philosophical stance taken on one’s research and it involves description of the intended data collection methods coupled with analysis and interpretation of the data collected. The importance of choosing the right methodology for any particular research cannot be overemphasised because it is the methodology that defines the methods and procedures to be used. Thus, the credibility of any research findings, conclusions or recommendations depends upon the methodology being used. However, it is important to note that research methodology cannot be described as true or false but only described as more or less useful (Silverman 2005).

There are different methodological models used in research which can be broadly defined into two categories:

Quantitative research concerns quantities, measurements and statistics and it commonly gives quantifiable/quantitative information to show that there is a factual relationship within the data collected. Quantitative research is based on realism/objectivism and the epistemology is positivism. It is pure, outsider research, impersonal and uses statistical analysis. The positivist methodology concerns scientific methods and uses rules and laws that are universally applicable to test hypotheses. Positivist researcher holds the view that science is real and that “knowledge is unambiguous, accurate and certain” (Illing 2007, p5). Experimental and survey researchers are associated with quantitative research.

Qualitative research is quite subjective and involves in-depth exploration of things in their natural settings in order to make meanings from them. Qualitative research is constructivist, interpretive, ethnographic and closely associated with anti-positivism. It is also naturalistic, applied, and individual and uses non-statistical analysis. The concept of qualitative research is that thorough understanding of social phenomena is obtainable through qualitative data /non scientific methods (Silverman 2005). In qualitative research, the theories and concepts are normally developed after data collection and the following research approaches are associated with qualitative research: Ethnographic research, Case studies, Phenomenological research, Grounded theory, Narrative research, Hermeneutics and Action/Participative research.

There could be a large difference between these research approaches, but Lingard and Kennedy (2007, p4) stated that they are linked by “common aim to explore social processes through interpretation of qualitative data”. Although qualitative and qualitative research designs are the most common, there are instances where the research study seems to be more quantitative than qualitative or vice versa; and between the two lays the mixed methods research.

The mixed methods research involves mixing of both qualitative and quantitative approaches to collect data so that the strength of the study is either more than quantitative or qualitative research (Creswell, 2009). The mixed methods research is based on the belief that collecting data using different methods will provide adequate answers to the research problem/question and the results could be generalised to the population.

Generally, qualitative research tries to find answers for how questions, whilst quantitative research finds answers to why questions. However, there is a common mistake by many people by believing that it is research designs/strategies (such as survey, case study, etc) that define whether the research is qualitative or quantitative. The determination of whether a research is qualitative or qualitative depends upon one’s research objectives/questions, strategy and methods used to collect data (Biggam 2008).

The research question for this study is – ‘ What are the views, attitudes and concerns of nurses on the role of appraisal and revalidation in improving their clinical performances?’ The main objective of this research question is to seek knowledge based on the personal opinions, views, concerns and attitudes of research participants with a view to make both statistical analysis and interpretation of the research findings.

The research design for this study is ‘ cross-sectional survey’ and the reason for selecting this design is to generate both qualitative and quantitative descriptions of the views, attitudes and concerns of nurses by studying a sample of their population with a view to make generalisation/claim their population.

The data collection methods used for this research is questionnaire and focus group discussion. These methods have been chosen to generate both quantitative and qualitative data. The questionnaire has both closed and opened questions to generate quantitative and qualitative data respectively. The focus group discussion is mainly to obtain qualitative data. As mentioned earlier, the reason for collecting the quantitative data is to find answers to questions and qualitative data to find answers to why questions.

With reference to the research question/objective, the design and methods used for this study as described above, the most appropriate methodology for this study is primarily qualitative research with some element of quantitative approach. However, it is believed that using positivist research methodology could make one to concentrate on the main findings of his/her research and perhaps ignoring the important views from the minority ones. Another critique of using positivism is that it may not be possible to use randomisation at all time and there could be structural limitations or observer bias and sometimes the data collected would not explain why things are as they are ( Pring 2004; Cohen et al 2007).

Research Question

The overall aim of this study is to investigate the views, attitudes and concerns of nurses about appraisal and revalidation and its effects on their clinical performances.

The specific research question for this dissertation is - What are the views, attitudes and concerns of nurses on the role of appraisal and revalidation in improving their clinical performances?

This study is also intended to answer the following supplementary questions:

1. What is the perceived difference between appraisal and revalidation, and the different types of appraisals?
2. What are the perceived reasons behind the introduction of appraisal and revalidation to the healthcare sector?

Ethical Issues

The importance of ethical issues in a research study cannot be overemphasised. The term ‘ethics’ in the research context “refers to the principles, rules and standards of conduct that apply to investigations” (McMillan & Weyers, 2007, p211). In a recent book, McMillan & Weyers (2007) stated that any research that involves human beings, participants and researchers’ dignity, human rights and health and safety should be protected. Thus, since this study will involve human beings there is a potential risk for a participant’s human right or dignity to be compromised and all procedures will be followed to avert this risk. The evolution of research ethics came about following the end of the Second World War, when details of horrific medical experiments came to light during Nuremberg trials. Illing (2007) stated that the Nuremberg Code (1947) was published two years later, followed by the Declaration of Helsinki (1964) and the World Medical Association. According to Opie (2004) ethics is all about moral principles to prevent harming or wronging others, to promote the good, to be respectful and to be fair.

“Without adequate training and supervision, the neophyte researcher can unwittingly become an unguarded projectile bringing turbulence to the field, fostering personal trauma (for researcher and researched), and even causing damage to the discipline” (Punch, 1994: 93; cited in Opie, 2004, p24).

Although these words may sound alarmist and extreme and unlikely to apply to me for my small scale research project as part of my master’s thesis, it is the case that any research involving people has the potential to cause (usually unintentional) damage. There is little potential health risk involved in this study, but still all efforts will be made to avoid causing any potential unintentional damage.

Thus, in conformity with the foregoing statements, an application form was submitted, on January 12, 2010, to the Health & Social Services Ethics Committee of States of Jersey for ethical approval of my proposed research study as part of my Master’s thesis. On 9th February, 2010 I was invited to a meeting by the Ethics Committee to give more details about my proposed research study and to answer some questions relative to the study. At the end of the meeting some corrections were made to the research information sheet before any final approval can be made. The revised information sheet was submitted to them on 15th February and ethical approval received on 14th April, 2010 to proceed with the study.

All the research participants were given Research Information Sheet, which included the following information:

- The aim/purpose of the study
- Description of the voluntary nature of the participation
- Description of the procedure of to be followed in the study
- Advantages and disadvantages of participation
- Confidentiality and anonymity nature of the study
- Information about outcomes of the study
- Funding information

A covering letter inviting participants to join the research study was also provided. Informed Consent forms were also given to each participant, which must be signed before any person can participate in the study. The informed consent form had been countersigned, with date by me prior to sending them to participants to express to participants that I will keep my promise/agreement (Denscombe, 2007). The Research Information Sheet and the consent form had both explicitly highlighted the anonymity of the research participants. An anonymous study is ‘one in which nobody (not even the study directors) can identify who provided data on completed questionnaires’ (Walonick, 1993, p5; cited in Berdie, Anderson, Niebuhr, 1986, p47). Although the Health and Social Services Department had reimbursed 80% of the cost of my final year tuition fee through the Education, Learning and Development Unit, there was no conflict of interest.

Methods

This is another important part of the research study and it concerns the way the data is collected, analysed and interpreted. The choice of methods to be used depends on what type of data you intend to collect and the research question.

After approval from the Ethics Committee and before the starting of the study, I had two meetings with the Head of School of Nursing, Education, Learning and Development and Head of Risk Management to discuss my research and the questionnaires. All the ward managers were sent an email letter informing them about the research study, who in turn also informed their individual ward staff about it. A week later, a letter was circulated to all the trained nurses working within Health & Social Services (HSS) through staff emails inviting them to participate in the study.

The research design is cross- sectional survey and it has been defined as “one that provides a ‘snapshot’ of a population at a particular point in time” (Cohen et al 2007, p213; Greenhalgh, 2006a, p51 & 2001b, p53 ) or “snapshot’ of the outcome and characteristics associated with it, at a specific point in time” (Levin 2006, p24). This design has been chosen to enable one to provide both qualitative and quantitative/numeric descriptions of the views, attitudes and opinions of nurses, in relation to the role appraisal and revalidation in improving clinical performance, by studying a sample of their population, with the data collected at one point in time. The aim of the research design is to generalise from a sample to a population so that conclusions can be made about some characteristic, or behaviour of the population of the nurses. Creswell (2009) explains that survey design can also help one to make quantitative descriptions of trends, attitudes, or opinions of a population by studying a sample of that population. From sample results, one could generalise or make claims about the population of the nurses. It may not be practically possible to know the views, attitudes or opinions of all the nurses in a particular hospital without employing a large number of observers, however, the use of survey design would help one to select a sample from the population of nurses within a selected site and build up the evidence which can be quantified – X% say this, Y% say that, and so on. However, since the design provides only a snapshot, Levin (2006) highlighted that different results could be generated at different times. According to Cohen et al (2007) large samples from cross-sectional surveys enable inferential statistics to be used, but argued that the design requires attention to be given to sampling, to ensure that the information on which the sample was based is comprehensive.

Cross-sectional surveys are not generally cheap, but when compared with other methods they are comparatively cheaper to administer and you can get a large volume of data in a short time (Denscombe, 2007). Both Cohen et al (2007) and Denscombe (2007) argued that there is low response rates associated with this design and trying to get a sizeable response rate from it can be quite difficult for the researcher; and also the accuracy and honesty of responses are questionable because some respondents may not answer specific questions or, wittingly/unwittingly, give incorrect answers.

Three settings (The General Hospital & two nursing homes – The Limes and Sandybrook) within the Health & Social Services (HSS) of States of Jersey were selected for the study. The HSS of States of Jersey was selected because they have appraisal and performance review for staffs and there had never been any research conducted on appraisal and revalidation; so it was a befitting opportunity for one to conduct research on the views, attitudes, and concerns of nurses on the role of appraisal and revalidation.

The study involved trained nurses working within the 3 selected settings and they were non-randomly selected, using purposive sampling; and the criteria used was that each participant must be a trained nurse and working within the three selected settings and willing to participate. Purposive sampling is an intentionally non random sampling method used to take a sample from a group of people/settings that have specific features relevant to your research study. Purposive sampling would help one to select the participants (nurses) among other staff within the selected settings on the basis of the specific features they have or the knowledge they have which is relevant to your research study ( Cohen et al, 2007, Silverman 2005). Although purposive sampling might be cheap, Biggam (2008) and Polgar &Thomas (2000) argued that it can bias your sample that is not representative of the population.

There are many different methods of data collection tools but with regards to this study, a mixed methods approach was used to collect data by combining questionnaires and focus groups discussions for the study with a view to get more insights and information from the participants. Multiple data collection methods can provide a deeper, convincing and accurate solution to the research problem (Yin 1994; cited in Casey & Houghton, 2010). In addition, mixed methods have been chosen so that both qualitative and quantitative data can be collected which could help the study to answer the how and why questions of the research objectives.

Using both questionnaire and focus group discussion will help me to compare the findings to see if there is any similarity and there is possibility that the two methods can compensate each other in terms of their strengths and weaknesses.

As a novice researcher, using two data collection tools needs skills with each of the tools and this could pose great difficulties to me. Findings from the two may not match/be similar and this can be very distressful. However, according to Denscombe (2007) the lack of similarities between the two methods should not be a hindrance but further studies should be conducted to find out why the difference in findings exist.

Focus group discussions

Focus group discussions are now a common method of gaining information and are a form of research data collection tool involving group of people with some common interest/characteristics and it is usually used to gather information about people’s beliefs, opinions, attitudes towards a focused issue (Bowling 2002; Nursing Planet 2009; Teunissen et al, 2007 ). Lingard and Kennedy (2007) added that focus groups can provide a dynamic and interactive exchange that can stimulate exploration of contrary opinions. The use of focus group discussions help to answer how and why questions in the research study.

However, both Bowling (2002) and Nursing Planet (2009) highlighted the uncertainty about the accuracy of what participants say because the presence of the researcher can influence the results. I am of the same view that my presence at the focus group discussion, which includes both junior and senior colleagues, could influence their opinions on the subject. McMillan and Weyers (2007) highlighted the tendency for focus group members not to discuss/participate in certain discussion/topics that are quite sensitive and I believe this may have an effect on some topics for the discussion. Barbou (2005) stated that focus group discussions provide data more quickly and at low cost, but Bowling (2002) and Nursing Planet (2009) argued that they are relatively chaotic, making data analysis more difficult and difficult to generalise findings because of the size of the group. I am aware of this it will have on my research but with proper data analysis techniques, I should be able to overcome this potential problem. After sending out questionnaires, a focus group discussion was organised with six participants. The participants were selected by purposive sampling and comprised both junior and senior nurses. A comfortable environment with refreshments was provided to the participants.

The participants were provided with informed consent form and guaranteed full confidentiality and anonymity. The procedure was explained to them before the commencement of the 60 minutes discussion. There was no skilled moderator, so I facilitated the discussion and also took notes. The participants were sometimes asked questions by me to clarify any point. The participants deliberated in length on the following topics:

1. Pre-appraisal and performance review assessment form
2. Performance review and appraisal
3. Performance review and appraisal to be part of revalidation process

Questionnaire

A self-administered questionnaire was sent out to participants to obtain. Polgar & Thomas (2000, p107) defined questionnaire as a ‘document designed with the purpose of seeking specific information from the respondents’. It is easy for one to statistically analyse questionnaires and a number of writers have mentioned that questionnaires are cheaper and can be very useful in large sample size studies with different settings than face-face interviews (Bowling, 2002; Opie, 2004; Polgar & Thomas 2000; Swetnam 2000; Walonick, 1993). Denscombe (2007) and Walonick (1993) narrated that questionnaires are associated with low response rates, incomplete answers and difficulty checking the truth of answers. The literacy level of the study sample also contributed to the selection of this design and according to Bowling (2002) self-administered questionnaires can be useful for sensitive topics as there is more anonymity and prevent the problem of the interviewer being present. Denscombe (2007) also stated that questionnaires are useful in investigating opinions, attitudes, views, beliefs and preferences of people, but Opie (2004) argued that whilst questionnaires provide answers to the questions What? Where? When? And How?, it is not so easy to find out Why? This method had also been used to avoid making participants apprehensive and allow them enough time to finish the questionnaires at their own pace (Walonick, 1993). The research questionnaires were developed through literature review and sample questions from a study conducted by Middlemass and Siriwardena in 2003 on GPs. Other relevant decision-makers, such as the Head of Education, Learning and Development and Head of Risk Management at HSS were involved in reviewing the questionnaire design process.

After the review, the instructions and layout of the questionnaires were modified together with any of the questions that were unclear. The ordering of question sequences were also reorganised to avoid similar questions following each other.

The questionnaires were piloted with two intended participants (due to the absence of two other intended participants) and modified to improve its clarity and remove any problems before the main survey (Polgar & Thomas, 2000).

“Questionnaires do not emerge fully-fledged; they have to be created or adapted,

fashioned and developed to maturity – it has to be piloted. Piloting can help not only

with wording of questions but also with procedural matters such as the design of the

letter of introduction, the ordering of question sequences and the reduction of non-

response rate” (Oppenheim, 1992:47; cited in Opie 2004, pp104)

Different colours were used, such as, white paper for questionnaires, yellow paper for informed consent form and green paper for research information sheet to make the study more appealing ( Berdie, Anderson and Neibuhr, 1986; cited in Walonick, 1993).

The questionnaire comprised semi-structured questions and open-ended questions. It consists of six open-ended questions on appraisal and revalidation and 19 attitudinal questions on appraisal and revalidation with traditional five-point Likert-type response formats – that is, strongly agree, agree, neutral, disagree and strongly disagree. The questions were very short and made of clear simple vocabulary with precise instructions on how to complete them to minimise confusion and make the questionnaire appear easier to complete (Walonick, 1993). There were questions on the views, attitudes and concerns of nurses about appraisal and revalidation and also their views about the effects of appraisal and revalidation on their clinical performances. On 17th May 2010, one hundred self-administered questionnaires were distributed to nurses working at The General Hospital and two nursing homes within Health & Social Services. Each questionnaire was enclosed with an invitation letter to participate in the study, Information Sheet about the research, Consent Form and a self-addressed stamped reply envelope in order to get better response as some investigators have suggested that people might feel ‘constrained to complete the questionnaire because of the guilt associated with throwing away money’ – that is, the postage stamp (Moser, 1971; Scot 1961; cited in Walonick, 1993). The participants were given a two weeks period to return their completed questionnaires.

Problems Anticipated and How They Were Overcome

Access to Settings and Participants

One of the first problems anticipated for my study was getting approval from relevant authorities or getting a ‘gatekeeper’ to help open doors to the necessary contacts and settings (Denscombe, 2007) and to overcome this, I organised a meeting with the Head of Education, Learning and Development of HSS to give me an idea of accessing the settings and participants. From the outcome of the meeting, I sent an application form to the chairman of the Health and Social services Ethics Committee for ethical approval. I was invited for a formal meeting by the ethics committee to provide more details about my proposed study and also to clarify any issues related to it. Some corrections were made relating to the research information sheet and later sent back to them for final ethical approval, which was granted after writing a reminder letter to the chairman for not receiving any response from him for so long. To help open doors to my necessary contacts/participants, the Director of Nursing and Clinical Governance was also informed about the study, who in turn asked both the Head of Education, Learning and Development, and Head of Clinical Risk Management to have a meeting with me and to give support.

Response Rate

Literature on research has response rates play an important part of the credibility and reliability of the research and to get a high response rate proves to be a major problem in survey research (Cohen et al, 2007; Walonick, 1993). To increase the response rates or overcome the problem of poor response rates, the following actions/measures were taken:

- Two pre-notification letters were sent out so that participants would be well informed, thereby contributing to a respondent’s trust and increase in response rate( Dillman, 1978; cited in Walonick, 1993). The first letter was written to all ward managers informing them about the research study and my intended visit to the wards to meet nursing staff and the second one was a general circulation to all nurses and other staff within HSS and this was done a week after the first letter. The pre-notification letters explained brief details about me, the purpose of the study, why nurses were chosen for the study, the importance of completing the questionnaire and how the results would be used.
- The general layout and format of the study was also put into consideration as this would also exert an influence on response rate (Cohen et al 2007; Walonick, 1993). The questionnaires were reviewed and piloted and corrections made. Different colours were used – white paper for the questionnaires, yellow for the informed consent form and green for the research information sheet – to make the study more appealing.
- The questionnaires were distributed to the ward managers by me for redistribution to their staff. Each questionnaire was sealed in an envelope with a brief covering letter, information sheet about the research, consent form and a self-addressed stamped reply envelope to increase respondent rates. The covering letter was personalised with my handwritten signature and it had been mentioned in the letter that 80% of the cost towards the study was reimbursed by HSS to show institutional affiliation in order to increase response rate. The dateline date was also mentioned in the covering letter to accelerate the return of questionnaires.
- An intensive follow up on non-respondents was to increase response rates (Cohen et al 2007; Walonick, 1993). During the second week of the deadline date for return of the questionnaires, telephone calls were made to different wards and also an email reminder was sent to all the ward managers to remind their staff to complete their questionnaires. A follow-up postcard was delivered to each ward by me to thank all those who had taken the questionnaires and to remind them to complete them. Another follow-up email was generally circulated to all the nurses and staff within HSS.

DATA ANALYSIS

Data analysis process for focus group

The process of thematic analysis, which identifies in the data set instances that are similar in concept, was used to analyse the data (Lingard & Kennedy, 2007). The data were collected and organised according to the ideas and concepts (themes/codes) expressed by participants in each topic discussed, and the ‘similarities and differences explored until saturated, at which point a set of generalisations was generated’ (Casey & Houghton, 2010). The set generalisations were analysed and interpreted. The final report was given to participants to read and make comments, but all agreed to the report.

Data analysis process for the questionnaire

Both quantitative and qualitative methods had been used to analyse the data. Chi-square was used to test the differences between some questions. Descriptive statistics had been used to present the data from closed questions. Closed questions are those where respondents are asked to indicate their answers by ticking the relevant responses. To analyse the closed questions, I decided to combine strongly agree/agree under one category and strongly disagree/disagree under another category, and keep the middle category neutral . The response rates had been shown for each of the closed questions with percentage figures representing the incidence of respondents choosing to answer a particular question as shown in table 1&2. Tabular forms and percentages were used to present the descriptive data because tables are a very common, convenient and straightforward method of displaying data; whilst percentages are easy to calculate and understand (Opie, 2004). For the purpose of the qualitative analysis, all comments made in the open-ended questions in the questionnaires were coded and analysed according to individual questions.

RESULTS

Focus group discussions

Pre-appraisal and performance review assessment form

All the six participants stated that they felt nervous in completing this form and one of the participants stated: “I don’t know what to write in the assessment form for fear of being different from the manager’s own”. Participants expressed that they were enthusiastic the first time they completed the form, however they all stated now that the forms were useless and boring because the same questions and answers were repeated every year”. Four of the participants stated: “we only submitted photocopies of our previous year pre-appraisal and performance review assessment forms to our line manager for this year’s appraisal. During the discussion, the participants expressed concern about the inconsistency of the forms used – “different forms had been used by different appraisers/line managers- and stressed that there should be one standard form to be used by all line managers/appraisers”.

Performance review and appraisal

All the participants acknowledged that performance review and appraisal, if done properly, would develop them and improve patient care, but they felt that it appeared to be about “managers ticking boxes and not about identifying the needs of the nurses to progress”. There were also concerns that the managers don’t support staff to obtain their appraisal set objectives and career development. Five of the participants mentioned that – “staff were not treated equally – some were given more chances to attend training courses than others- by some managers; and this sometimes resulted in friction within staffs”. When asked about their views/opinions whether performance review and appraisal has any effect on their clinical performances, all the participants indicated that this had no practical benefit/bearing on their clinical performances. All the participants stated: appraisal is only theoretical or black and white and had no practical effect on our clinical performances”.

One of the participants mentioned:

“We are not given choices to set our objectives, the manager is always subjective and there is lack of support; so how can appraisal have any effect on our clinical performances?”

However, all the participants agreed that performance review and appraisal would help them to discuss their career aspirations, identify their individual training and development needs, feelings about their work and suggest any changes for the care of the patients.

Performance review and appraisal to be part of revalidation process

All the 6 participants suggested that patients and the general public should not be involved in the NMC revalidation process. The 6 participants also expressed: “we feared that the personal relationship between the appraiser (line manager) and the appraiser could influence the outcome of the appraisal, which could subsequently affect the validity and reliability of the revalidation process”.

However, participants agreed that performance review and appraisal should be part of NMC revalidation process because they “felt that the current NMC revalidation process is not robust enough and needed reviewing”.

Questionnaires

Responses

The response rate for the total sample (100) was 55% during the period of four weeks after three follow-up reminders. The majority of respondents (38.2%) were between the ages of 40 – 49 and there was an equal number (23.6%) between the ages of 33-39 and 50-59 as shown in table 3. There was 100% response rate to all the closed-ended questions (Tables 1 & 2); and there was 54.5% least response rate for open-ended questions with 83.4% total average response rate (Table 4). Despite relatively low response rate, the respondents were well spread across all specialities/wards within the hospital and two nursing homes sampled.

Close questions on appraisal

Responses to the closed questions on appraisal revealed that 92.7% of the respondents believed that appraisal is a confidential process and 41.8% believed only learning needs should be disclosed. The P value between the two questions was 60.40, less than .05, using chi-square. Over half of the respondents (56.4%) in table 1 agreed that assessment and appraisal were the same and compared to 18.2% in table 2 who disagreed, revalidation and appraisal are the same, showing p value of 0.23, p<.05. Less than half (49.1%) were generally in favour of appraisal. Majority (61.8%) agreed that the introduction of appraisal into the NHS was to improve the clinical performances of healthcare workers, but less than half (36.4%) believed the introduction was due to a series of national scandals and poor practices (Table 1).

Table 1 Responses to statements on appraisal

Number and % of total respondents of 55

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Closed questions on revalidation

As shown in table 2, less than half (38.2%) of the respondents agreed that revalidation was not a confidential process and 40% were neutral about it. About two-thirds (65.4%) agreed that CPD was an important part of the revalidation process. Almost half (49.1%) disagreed that patients and public involvement at all stages of the revalidation process would greatly enhance its quality and promote confidence in the nursing profession and 45.4% believed that revalidation and appraisal were the same.

Three-quarters (74.5%) agreed that the appraisal process should be developed locally and 45.5% believed that feedback on nurses’ performances would enhance reflective care and should be part of appraisal and revalidation process. Less than half (43.6%) of the respondents were in favour of revalidation (Table 2)

Table 2 responses to statements on revalidation

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Table 3 Age comparisons

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Table 4 Comparison of responders on each opened-ended question answered

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First questionnaire: what do you understand to be the main purpose for performance review and appraisal?

As shown in table 4, 92.7% responded to this question and the majority (96.1%) of respondents mentioned that the main purpose for performance review and appraisal was to check the strength and weakness of staff work performances and also to identify their educational and training needs. Respondents also stated that performance review and appraisal would promote critical reflection of practice and promote self development, which gives an opportunity to discuss nursing practice issues with line managers to meet NMC competence. They also believed that recognition of one’s knowledge and achievements can be promoted through performance review and appraisal.

Second questionnaire: when did you last to have a performance review and appraisal?

This question revealed that 98.1% of the respondents have had their performance review and appraisal, but 39% of them last to have their performance review and appraisal for more than a year and 22.1% for more than two years; and one respondent had never had one since employed 4 years ago(Table 5).

Table 5 Responders last performance review and appraisal comparison

Number and % of total respondents of 54

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Third questionnaire: what do you think of the current appraisal process?

More than half (51.9%), of the respondents, as seen in table 6, were not satisfied with their current appraisal process and claimed that their current appraisal process was “full of paperwork and time consuming which put off staffs; and also made it difficult for line managers to conduct regular annual appraisals''. The p value was 4.56, p<.05, between those who were satisfied with their current appraisal and those wanted to see changes . Respondents stated that they felt their current appraisal process is just more of paper exercise as it does not seem to yield much benefit to the staff. The appraisal process “does not push for follow up review and lack guidance plan for nursing profession and most line managers do not support their staff to achieve their set identified educational objectives due to staff shortage or lack of time with line managers”.

Table 6 Responders comparison on their current appraisal process

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Fourth questionnaire: would you like to see changes? If yes, what changes?

Large number (68.5%) of respondents wanted to see the following changes with their current appraisal process:

- Less paper work and easier assessment form
- More focus on training and development needs and achievements
- Regular yearly appraisal and six-monthly meeting with the line manager to review progress regarding set objectives
- Consistency in the appraisal process
- Advocating for a 360 degree appraisal system to have a balanced/objective judgement.

Fifth questionnaire: how will lack of performance review and appraisal affect your clinical performances?

Majority (61.4%) of the respondents, as shown in table 7, believed that lack of performance review and appraisal would not give them the opportunity to express concerns and aspirations regarding their personal training and development which could result in low self-esteem and less value. The respondents also expressed concern that lack of performance review and appraisal “could deny their chances of attending training courses to update their clinical knowledge and skills because their learning needs would not be noticed by their managers”. Respondents stated: “good or bad clinical practises and reduced evidence-based practice would go unnoticed if there was no performance review and appraisal”. However, few respondents (38.6%) mentioned that performance review and appraisal are confidence boosters and lack of them would not have any effect on their clinical performances or influence the quality of patient care.

Table 7 Responders comparison on lack of performance review and appraisal

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Sixth questionnaire: what is your view about revalidation in improving clinical performances of nurses?

As shown in table 8, more than half (67.6%) of the respondents believed that revalidation can improve clinical performance of nurses because it ensures fitness to practice, but however, they stated that “there was no practical/tangible evidence to support this notion”. They all stated that the current NMC revalidation process would “not improve clinical performances of nurses because NMC never asks for evidence of CPD”.

Table 8 Responders view about revalidation in improving clinical performances

Abbildung in dieser Leseprobe nicht enthalten

Seventh: what is your view about your annual performance review and appraisal being part of your revalidation process?

Many respondents (66.7%) supported the idea for annual performance review and appraisal to be part of the revalidation process, but feared that this could put more burden/pressure on the line managers who are already not able to conduct annual appraisal on their staffs regularly. They stated that the process could quickly identify any training needs of nurses, which could be resolved before revalidation. However, the p value between those who were in favour of performance review and appraisal to be part of revalidation was 7.36, p<.05

Table 9 Responders view about performance review and appraisal being part of revalidation process

Abbildung in dieser Leseprobe nicht enthalten

DISCUSSIONS

The results of this study have shown different views, attitudes and concerns of nurses towards appraisal and revalidation in improving clinical education.

Despite the relative low response rate of 55%, the respondents were well spread across all specialities and wards. Study participants stated they were nervous in completing the pre-appraisal and performance review assessment form, which could be due to their past experience. However, literature review has shown that the previous experience of the appraisee and the relationship between the appraiser and the appraisee will all have an effect on the performance review processes (Redshaw, 2008).

This study had shown that there are still divided opinions about appraisal and revalidation as more than half (61.4%) of respondents believed that appraisal and performance review could identify individual training and development needs. However, 38.6% of the respondents felt lack of it would not have any negative effect on their clinical performances. They view appraisal as only theoretical with no practical evidence in improving clinical performances.

However, literature on appraisal has shown that there is much ‘indirect research evidence that indicates that reviewing one’s work objectives, strategies for meeting them, training needs and working relationships lead to improved performances’ (West, 2002). There were different views about assessment, appraisal and revalidation – 56.4% agreed that assessment and appraisal were the same and 45.4% agreed revalidation and appraisal was the same (see Table 1&2). The study also highlighted that almost half (49.1%) of respondents did not want patients and public involvement in their revalidation process, but 66.7% wanted performance review and appraisal to be part of it.

There was lack of regularity in the conduction of the annual performance review and appraisal at the sample settings as 39% of respondents did not have their performance review and appraisal for more than a year and 22.1% for more than two years. More than half (51.9%) were not satisfied with their current appraisal process and 68.5% wanted to see changes such as less paperwork, easier assessment format, more focus on training and development needs, regular annual appraisals and introduction of 360 degree appraisal system to have more balanced/objective judgement (Table 6).

Almost three-quarters (74.5%) of respondents agreed that appraisal process should be developed locally; and Dangerfield (2003) stated that successful appraisal system depends on the involvement of staff (who are going to implement the system) in designing and implementing the scheme and evidence has shown that appraisal systems don’t last long if they are developed from top management to junior/lower staffs.

Everybody wants to support what he/she has created and thus, for the appraisal system to work well in an organisation it has to involve everyone in developing the system. More than half (67.6%) believed revalidation can improve clinical performances, but expressed concern that the current NMC revalidation process would hardly realise this because NMC have not been asking for evidence of CPD from nurses.

The literature review has generally shown that there is a difference between appraisal and revalidation, although some people still think they are the same as manifested in this study by some participants. As evidenced in this report, some nurses still believe that appraisal and revalidation will not have any effect on their clinical performance and some even questioned the role of NMC revalidation process for nurses. The study findings have also shown some degree of collaboration between the two methods used.

Potential limitations of this study

The response rate (55%) was relatively low (less than the anticipated rate of 60%) from sample size of 100 which could be due to the sampling method used for settings and participants; ignorance of the topic; dislike/sensitivity of the topic/contents or even personal disliking/lack of empathy with the researcher by participants. However, generally low response rates is one of the weaknesses of questionnaires and this study has been a victim of this. Nevertheless, this study remains the first of its kind to be conducted at the sample settings. The lack of non-respondents to some individual survey items coupled with a relatively low response rate, may all have contributed to non-response bias and affect the face and content validity of the questionnaire. The questionnaire was piloted with only two participants due to the absence of two other respondents invited for the pilot study, which might also have contributed to non-respondents to some survey items and possible low response rate. The participants were purposely sampled and given questionnaires to fill at workplace or home, which could add potential biases in the results, for example, it is possible that the participants had shared their answers with each other or someone had filled the questionnaire for them.

The focus group discussions could also contribute biases in the results because the participants were my co-workers, comprising both junior and senior staff; and it is possible that some of the comments/answers made were influenced by the presence of senior staff/colleagues or even myself. The experience of this study has demonstrated some of the difficulties in collecting data using questionnaire and purposive sampling method; and future studies in these areas need to consider these perspectives.

Another lesson learnt from the study was the sample size and use of questionnaires that made it difficult to obtain high response rate and in future studies it would benefitting to minimise the sample size by randomised sampling to have representative of the study population and conduct focus group discussions and or interviews rather than questionnaires. The mixed methods used for this study had also made it very difficult to analyse and interpret the results properly and in future studies proper consideration will be given to this.

Undertaking a pilot study of a questionnaire is very vital and it would have had a great impact on my questionnaire and non-respondent rates if I had properly piloted my questionnaire with more than two participants. Despite exploring all the possible means of encouraging higher response rates, this study has shown me that it is very difficult to obtain higher response rates in questionnaires.

Institutional affiliation through survey sponsorship by Health & Social services of States of Jersey had been acknowledged to participants and this might have created fear by participants, resulting in low response rates. Therefore, in future research study, one has to be very cautious about the pros and cons of affiliating with institutions through sponsorship.

This study also has some limitations regarding the researcher’s knowledge and skills in conducting a study like this. Although the researcher had completed a module on research studies, this is the first time to be practically involved in conducting a research study.

English bias - The researcher’s first language is not English which could be noticed by some readers.

CONCLUSIONS AND RECOMMENDATIONS

The overall purpose of this cross-sectional survey study was to investigate the views, attitudes and concerns of nurses about appraisal and revalidation and its effects on their clinical performances and this study had identified the following areas:

- There were still different views/opinions about appraisal and revalidation and lack of understanding between the two.
- There was also lack of understanding between assessment and appraisal
- There was strong opposition about patients and public involvement in the revalidation process of nurses
- There was little understanding about the reasons for introduction of appraisal and revalidation into healthcare sector
- There was a need for review of current performance review and appraisal process within the sampled settings
- There was a strong call for regular annual performance review and appraisal within the settings.
- Majority of the nurses in the study believed that appraisal and revalidation could improve their clinical performance

The limitations of this study, including issues relating to the response rate and sampling methods, might have reduced confidence to claim that the study had achieved the representative views of the broader nursing profession at HSS of States of Jersey or be generalised to the wider research community. However, this study finding was an opportunity for relevant authorities at HSS to know the views and opinions of nurses towards their annual performance review and appraisal process, which has not been reviewed since its inception.

Finally, in view of the study findings, there is still need to research into the views of nurses towards appraisal and revalidation that could represent the broader views of the nursing profession. It may also be necessary to research into the views and attitudes of nurses towards patients and public involvement in appraisal and revalidation process

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APPENDICES

A. Ethical approval email by the secretary

From: Paul McCabe

Sent: 15 April 2010 08:29

To: Papa Keita; Alison Potts (Secretary)

Cc: Tarina Le Duc; Julie Mesny

Subject: RE: Ethics application

Papa, Thanks for your letter of 8th April and copy of the revised information sheet. I am pleased, therefore, to be able to confirm a favourable ethical opinion in respect of your proposed study. Kind regards Paul Paul McCabe | Chief Pharmacist Health and Social Services Department General Hospital | Gloucester Street | St Helier I Jersey |

B. Circular to ward managers

To: Ward Managers

Subject: Distribution of a Research Study Questionnaire

Research Title: Cross-Sectional survey on nurses’ views, attitudes and concerns about appraisal and revalidation in improving clinical performances

Dear All, I am researching for my Master’s thesis in clinical education at the College of Medicine and Veterinary Medicine, University of Edinburgh and I am writing to formally inform you that in the next few days I will be coming around to distribute the research questionnaires to trained nurses within your individual wards/units across The General Hospital, The Limes and Sandybrook.

The research study has been scrutinised by the Health and Social Services Ethics Committee and granted approval; and 80% of the cost towards this research study has been reimbursed by Health and Social Services through the Head of Education, Learning and Development Unit. In addition, the following people are fully aware of this research study:

- Director of Nursing and Clinical Governance
- Head of Education, Learning and Development Unit
- Head of Risk Management

Thus, in view of the foregoing, I would be most grateful if you could kindly give your support to make this study successful.

Please do not hesitate to contact me if you need any further details.

Yours sincerely, PsKeita

Papa Keita | BSc, SCM, RN, Dip Mngt&Admin |

Tel: workplace: ext – 443831; Mob: [phone]; email: [e-mail]

C. Invitation to participate in the study

To: All Trained Nurses

Subject: Invitation to Participate in a Research Study

Research Title: Cross-Sectional survey on nurses’ views, attitudes and concerns about appraisal and revalidation in improving clinical performances

Dear Colleagues, As I mentioned in my previous letter (circulated to all HSS Users on 10th May), I am researching for my Master’s thesis in clinical education at the University of Edinburgh and I am inviting you once again to participate in this research study to investigate the views, attitudes and concerns of nurses about appraisal and revalidation in improving clinical performances within The Limes, The General Hospital and Sandybrook.

There are many different views and concerns about clinical performances in relation to appraisal and revalidation and this research study will help me to better investigate and understand appraisal and revalidation in relation to clinical performances.

Please find enclosed the Informed Consent Form attached to the questionnaires for you to kindly spare a few minutes to fill them and return them back to me as soon as it may be convenient to you OR within 1 to 2 weeks, using the enclosed pre-paid returned stamped addressed envelope.

The Research Information Sheet is also enclosed for your perusal and retention.

Please, please I need the participation of as many nurses as possible to make the study more valid and therefore, I would be most grateful for your full participation .

Please do not hesitate to take the questionnaire with you at home to answer them if you are so busy in the ward.

Please, please I need your participation

Please do not hesitate to ask me if you need any further details.

Once more, thank you very much for your help at this busy time.

Yours sincerely, PsKeita

Papa Keita | BSc, SCM, RN, Dip Mng&Admin |

Tel: workplace ext: 443831 Mob: [phone] email: [e-mail]

D. Research questionnaire

APPRAISAL AND REVALIDATION – CROSS-SECTIONAL SURVEY

QUESTIONNAIRE

Abbildung in dieser Leseprobe nicht enthalten

Information Sheet

I am requesting your participation in my research study to investigate the views, attitudes and concerns of nurses about appraisal and revalidation in improving clinical performances.

- The purpose of the research study

The study is part of my Master’s thesis/dissertation in clinical education at the College of Medicine and Veterinary Medicine, University of Edinburgh. There are different views about appraisal and revalidation in improving clinical performances and this research study will help me to better investigate whether appraisal and revalidation actually contribute to nurses’ clinical performances.

- What does the study involve?

The study will involve face-face interviews for pilot study and followed by distribution of a self-administered questionnaire. The interview and the questionnaire should take approximately 10 minutes each to complete. There are no likely major risks involved in taking part in this study and there will be no payment for taking part in the study.

- Do I have to take part?

Your participation in the study is completely voluntary and you do not have to take part if you do not want to. You can withdraw from the study at any time or avoid answering questions which you feel are too personal or intrusive even after signing the consent form. If you withdraw from the study at any stage of the study your information will be destroyed and will not be mentioned in the report. If you agree to take part in the study, you will be asked to sign a consent form. In order for my study to be more valid, I will need the participation of as many nurses as possible and therefore, I would be most grateful for your involvement.

- Will my participation in this study be kept confidential?

All the information given to me will be treated in the strictest confidence and will be used only for the purpose of the research study. Your name on the consent form will be removed from the questionnaire before analyzing the data. The research study will be anonymous, meaning no individual names will appear or mention in the research study report.

- Ethical approval – who has approved the study?

The study will be/has been scrutinized by the Health and Social Services Ethics Committee and granted approval. I will be entirely supervised throughout the research study by Professor (Dr) David Blaney at the College of Medicine and Veterinary Medicine, University of Edinburgh.

- What will happen to the results of the study?

The results of the study will be part of my Master’s thesis which will be forwarded to the University of Edinburgh and also a copy kept by myself, but anonymity will be maintained and at no time will the identity of individual participants appear or mention in this information.

Once more, thank you very much for taking your time to read this information sheet and please do not hesitate to contact me if you have any queries or questions.

My contact details:

Email: [e-mail] or [e-mail]

Tel: workplace – ext: 443831 / home: 01534618697

Mob: [phone]

F. Informed consent form

Informed Consent Form for Research Study Participants

Research Title: Cross-Sectional survey on nurses’ views, attitudes and concerns

about appraisal and revalidation in improving clinical performances.

I agree to take part in the above research study as part of Master’s thesis in clinical education at the University of Edinburgh. I have had the project explained to me and I have read the Information Sheet, which I may keep for my records. I fully understand that agreeing to take part in the research study means that I will be willing to:

- be interviewed by the researcher

- complete self-administered questionnaires

I understand that any information given will be treated confidentially and used only for the purpose of the study, and that no individual names or any identifiable data will be mentioned in the research reports or to any other party. I understand that a copy of the research study reports may be kept in the library of the University of Edinburgh for future references but no identifiable personal data will be shared with any organisation.

I understand that my participation is voluntary, that I can choose not to take part in any part or all of the research study, and that I can withdraw at any stage of the research without being disadvantaged in any way

Full Name (please print):..

Signature:...Date:..

Signature of principal Investigator:Date:.

Abbildung in dieser Leseprobe nicht enthalten

[...]

• College: University of Edinburgh (College of Medicine and Veterinary Medicine)
• Grade: Pass
• Author: RGN, MSc(clin.Ed), MSc (Int. Dev), BSc, SCM, Dip in Legal & Ethical Issues Papa Keita (Author)
• Publication Year: 2010
• Pages: 73
• Catalog Number: V1165502
• ISBN (eBook): 9783346637925
• Language: English
• Tags: cross-sectional