Policy reform in nurse education and its implementation in the Caribbean region Andrea F ...

345 Pages·2017·2.84 MB·English

Policy reform in nurse education and its implementation in the
Caribbean region

Andrea F. Brathwaite

Submitted in accordance with the requirements for the degree of

Doctor of Education

School of Education

University of Sheffield

October 2017
Andrea F. Brathwaite Thesis
Abstract
In 2006, the Caribbean Community (CARICOM) – a federation of sovereign
Caribbean states – decided that the Bachelor of Science in nursing degree would be
the standard qualification for entry to nursing practice in its English-speaking member
countries. Indications were that by 2011 all of the English-speaking states had not
implemented the regional policy. This research study was conducted to reveal the
origin and nature of the 2006 CARICOM nursing education reform, trace its pattern
of implementation, and determine the implications of that pattern for the coverage and
coherence of healthcare in the region. An interpretive study with a multiple case design
was conducted. Six case units were investigated through a staged approach to this
empirical study. The research drew on the findings of interviews with selected policy
actors, and on findings from the review of relevant documentary sources.

The main findings were that the reform was not fully adopted in the region; that system
tensions delayed its implementation; and that country-specific factors produced the
variation in its adoption by member states. These findings have implications for the
harmonization of nursing across CARICOM and, by extension, for CARICOM’s
functional cooperation in nursing services. They also have implications for the
region’s accomplishment of the World Health Organisation’s objective of universal
access to quality healthcare – part of its Universal Health Coverage by the year 2030
agenda. The results should be useful to Caribbean and international health and
education policy scholars and actors.

Key words: nursing, higher education, education reform, policy implementation,
Caribbean, CARICOM
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Andrea F. Brathwaite Thesis
Acknowledgements
“If I’ve seen further, it’s by standing on the shoulders of giants.”
Sir Isaac Newton, 1676

In tribute to the Caribbean nurse leaders of the past and those who continue their
struggle today. With profound gratitude to this study’s participants, my supervisors,
and my supportive family and friends. Thanks for letting me stand on your shoulders!

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Andrea F. Brathwaite Thesis
Table of Contents
Page

Abstract ........................................................................................................................ ii
Acknowledgement....................................................................................................... iii
Appendices .................................................................................................................. ix
List of Tables................................................................................................................ x
List of Figures ............................................................................................................. xi
List of Commonly Used Abbreviations ..................................................................... xii

PART 1: Introduction and Background ................................................................. 1
Chapter 1: Introduction to the Research ............................................................... 2

Aim and importance of the research ........................................................................ 2
Core and supplementary research questions ........................................................... 3
Research design, methods and data sources ............................................................. 3
Presentation of the findings ..................................................................................... 4
Significance of the research ..................................................................................... 4
Structure of the thesis ............................................................................................... 5

Chapter 2: The Caribbean Community: Structure, History and Responsibility
for Nursing .................................................................................................................. 6
CARICOM members, structure and governance .................................................... 6
Mobilization to advance nursing in the Caribbean ............................................... 13
Federation, independence, political union and their influence on nursing ........... 14
Governance of nursing in the Anglophone Caribbean .......................................... 16
Perspectives on Caribbean policy-making ........................................................... 17

Chapter 3: The CARICOM 2006 BScN Reform .................................................. 20

Contemporary economic and social features of CARICOM ................................. 20
Origin and nature of the BScN reform ................................................................... 24
RNB’s BScN surge ................................................................................................ 27
Building the model curriculum ............................................................................. 29
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Andrea F. Brathwaite Thesis
Expectations and plans for implementation ........................................................... 31
Contemporary provision and governance of nursing in CARICOM ..................... 32

PART 2: Conceptualizing the Research ................................................................ 38
Chapter 4: Features and Dynamics in Policy Systems ........................................ 39
Understanding policy dynamics .............................................................................. 39
Actors in policy systems ......................................................................................... 41
Contextual and actor influences on policy implementation .................................... 42
Policy characteristics and policy outcomes............................................................. 43
Policy dynamics in federal systems ........................................................................ 46
Insight from education policy scholars ................................................................... 48
Planning policy implementation ............................................................................. 50
Summary ................................................................................................................. 51

Chapter 5: Perspectives of Policy: Models and Processes ................................... 52
Top-down perspectives ........................................................................................... 52
Multi-directional perspectives on policy and power ............................................... 57
Health policy analysis ............................................................................................. 60
The Policy Evolution Model ................................................................................... 61
Explanation of the model’s elements ...................................................................... 63
Purpose and scope of the model .............................................................................. 68

Chapter 6: Research Design, Methodology and Methods .................................. 69

Research questions and design ............................................................................... 69
Positionality and issues of confidentiality ............................................................. 71
Ethics procedure .................................................................................................... 74
An interpretive design…. ....................................................................................... 75
A staged approach .................................................................................................. 79
Stage 1 – Desk Review .................................................................................... 80
Computer-mediated communication for data collection .................................. 81
Selection of and access to participants ............................................................. 82
Stage 2 – Interviews and documentary review ................................................ 87
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Andrea F. Brathwaite Thesis
Character and conduct of interview studies ...................................................... 88
Search, collection and analysis of documents ................................................... 92
Stage 3 – Analysis and synthesis of the findings .............................................. 94

PART 3: Findings and Implications of the Research .......................................... 98
Chapter 7: Introduction to Part 3 ......................................................................... 99

Desk review findings.............................................................................................. 99
Key features of the context .................................................................................. 104
Stage 2: Conducting the interviews and document analysis ................................ 105
Introducing the empirical findings ...................................................................... 106

Chapter 8: Early Engagers: Jamaica and The Bahamas ................................ 108

Jamaica’s nursing education context and sample description .............................. 108
Jamaica’s empirical findings ............................................................................... 108
Why BScN reform? ....................................................................................... 113
Jamaica’s reform intentions ......................................................................... 117
Jamaica’s BScN reform components ........................................................... 118
BScN reform’s evolution in Jamaica ........................................................... 118
Jamaica’s document findings ....................................................................... 129
Summary of Jamaica’s BScN reform episode ............................................. 134
Nursing education in The Bahamas ..................................................................... 136
The Bahamas’ empirical findings ........................................................................ 136
Why BScN reform? ...................................................................................... 136
Bahamas’ reform intentions ........................................................................ 138
Reform components .................................................................................... 141
Evolution of the BScN reform .................................................................... 143
Bahamas document findings ....................................................................... 156
Summary of The Bahamas’ engagement .................................................... 159
Comparison of Jamaica’s and The Bahamas’ reform processes ......................... 161

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Chapter 9: Late Engagers: Barbados and St. Kitts/Nevis .............................. 171
Nursing education in Barbados ......................................................................... 171
Barbados’ empirical findings ............................................................................ 171
Why BScN reform in Barbados?................................................................ 172
Barbados’ reform intentions ...................................................................... 172
Barbados’ BScN reform components ....................................................... 173
Barbados’ BScN policy evolution ............................................................. 174
Barbados’ document findings ................................................................... 193
Summary of the BScN reform’s evolution in Barbados ........................... 194
Nursing education in St. Kitts/Nevis ................................................................. 196
St. Kitts/Nevis’ empirical findings .................................................................... 197
Why BScN reform in St. Kitts/Nevis? ..................................................... 197
Reform intentions .................................................................................... 198
Components of the reform in St. Kitts/Nevis .......................................... 199
Evolution of the BScN reform in St. Kitts/Nevis .................................... 200
Summary of St. Kitts/Nevis’ findings ..................................................... 207
Comparison of Barbados’ and St. Kitts/Nevis’ reform processes...................... 209

Chapter 10: Dilatory Engagers: Grenada and Antigua/Barbuda .................... 211
Nursing education in Grenada ........................................................................... 211
Grenada’s empirical findings ............................................................................ 211
Why BScN reform in Grenada? ................................................................. 212
BScN components in Grenada .................................................................. 215
Grenada’s reform engagement .................................................................. 217
Grenada’s document findings ................................................................... 227
Summary of Grenada’s engagement to date ............................................. 229
Nursing education in Antigua/Barbuda ............................................................. 231
Antigua/Barbuda’s empirical findings .............................................................. 231
Reasons behind the reform in Antigua/Barbuda ...................................... 231
Reform intentions .................................................................................... 232
Reform components ................................................................................ 232
BScN reform engagement ....................................................................... 233
Document findings .................................................................................. 240
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Summary of Antigua/Barbuda’s reform process, to date ........................ 241
Comparison of Grenada’s and Antigua/Barbuda’s engagement processes........ 243

Chapter 11: Synthesis and Implications of the Findings ................................... 246
What were the reasons for the 2006 CARICOM BScN reform? .......................... 246
What was encompassed by the reform? ................................................................ 247
What plans, goals, expectations (intentions) were attached to the reform? .......... 248
What factors promoted or inhibited the realization of this policy? ....................... 249
How, and to what extent, was the reform implemented in member states? .......... 255
What are the implications of this implementation pattern? .................................. 257
Tensions in the system ......................................................................................... 258
Avenues for reform acceptance ............................................................................ 260

Chapter 12: Conclusion ........................................................................................ 262
Congruence with the literature .............................................................................. 262
Congruence with the Policy Evolution Model ...................................................... 264
Reflections on the study and projections for further research............................... 265
The Way forward for the BScN reform in CARICOM......................................... 266

References ............................................................................................................... 275

Appendices .............................................................................................................. 301

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Appendices
Appendix A: Information Sheet ........................................................................ 301
Appendix B: Participant Invitation Letter ......................................................... 302
Appendix C: Consent Form .............................................................................. 303
Appendix D: Pre-Interview Questions .............................................................. 304
Appendix E: Interview Protocol ..................................................................... 305
Appendix F: Jamaica’s Interview Findings...................................................... 308
Appendix G: Bahamas Interview Findings…………………………………..313
Appendix H: Barbados Interview Findings………………………………….317
Appendix I: St. Kitts/Nevis Interview Findings……………………………..322
Appendix J: Grenada’s Interview Findings…………………………………..326
Appendix K: Antigua/Barbuda’s Interview Findings…………………………330
Appendix L: Document Analysis Worksheet…………………………………333

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List of Tables
Table 3.1: Recent Nurse Education Provision in the English-speaking Caribbean . 36
Table 5.1: Top-down Perspectives on Policy ........................................................... 56
Table 6.1: Interview Sample Composition .............................................................. 85
Table 7.1: Desk Review Findings on Implementation of the BScN in CARICOM 101
Table 8.1: Early Engagers’ Reform Enablers ....................................................... 168
Table 8.2: Early Engagers’ Constraints ................................................................. 169

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