Preparing for an Unfamiliar Setting: A Grounded Theory for Nursing Education Collaborations

Purpose: There is a global shortage of qualified healthcare workers, and international collaborations have been identified as a strategy to address the global healthcare worker crisis. A gap in understanding and evidence exists however, for guiding individuals as they prepare for nursing education partnerships and international collaborations in unfamiliar settings. Much of the existing knowledge base is hidden within institutional or organizational confines. Contextual variations relating to nursing education and practice necessitate a deeper understanding of preparation processes for appropriate role enactment when transferring the nurse educator role to an unfamiliar setting. The purpose of this research was to generate a grounded theory that could guide nursing faculty in developing the knowledge base necessary for role enactment in an unfamiliar setting. Ghana, Africa was the context of the unfamiliar setting for this study.

 

Methods: Corbin and Strauss’s (2008) grounded theory methodology framed this research. Human subjects were protected through informed consent, Institutional Review Board approval from the researcher's institution in the United States (U.S.), and Ministry of Health approval and oversight in Ghana. The study began in September 2011, with purposive sampling of nurses from the U.S. who had firsthand experience preparing for enacting the nurse educator role in Ghana. In addition to firsthand experience with the phenomenon of interest, inclusion criteria included the ability to speak and converse in English, and a minimum age of 18. Purposive, snowball sampling progressed to theoretical sampling, via telephone interviews with ten U.S. participants. Data saturation was determined after the 10^th U.S. interview.  Theoretical sampling then transitioned via researcher fieldwork in February 2012, to face-to-face interviews with six key informants in Ghana experienced in partnering with outsiders for nursing education collaborations. Ghanaian participants were selected to enrich researcher interpretations by providing insider perspectives and knowledge to address questions raised by U.S. outsider participants. Data management included an inductive, constant comparative analysis process that began with the first U.S. interview, and continued until the final theory emerged.  Interviews were audio-recorded and transcribed verbatim by the researcher. Researcher transparency revealed experiences that shaped researcher perspectives, including a background in nursing education, nursing informatics, information literacy, and global mission efforts. In conjunction with Corbin and Strauss’ (2008) methodology, Saldana’s (2009) coding guidelines for qualitative research facilitated analysis. Data collection and analysis incorporated researcher memos, first-cycle open process coding, reorganization of coded data, second-cycle focused coding to identify relationships between categories, themes, and sub-themes, second-cycle axial coding that indicated their properties and dimensions, and mapping of concepts and their relationships until the overarching central category emerged that could logically and intuitively explain the final emergent theory in September 2012. TAMS Analyzer qualitative software was used to store, manage, code, and sort the data for analysis.  Member checks validated the transcriptions, and dissertation chair review helped establish credibility of researcher interpretations. Researcher thoughts, observations, and analytical decisions recorded as memos helped establish dependability and confirmability of findings as part of an audit trail. Rich, thick descriptions, including quotes from participants allow others to judge transferability of study findings to their context.

 

Results: Findings revealed antecedents and five process steps to outsider preparations that organized the emergent theory: Preparing for an Unfamiliar Setting, grounded in participant experiences. Progression through the process was fluid, allowing individualized interpretations based on antecedent characteristics. Antecedents included an individual’s existing knowledge base, experience, and network. The five process steps in order of occurrence included: (1) Personalizing Information Needs, (2) Seeking Information, (3) Laying the Groundwork, (4) Developing Understanding, and (5) Framing the Outsider Role.

When Personalizing Information Needs participants asked themselves: (a) what do I know? and (b) What do I think I need to know? Two main themes emerged in step 1: breaking new ground, and drawing on experience. When Seeking Information, participants asked themselves: how do I get the information I need? Two main themes emerged in step 2: networking (or its’ counterpart, ineffective networking), and searching for information. When Laying the Groundwork, participants asked themselves: (a) how do I know what is important to know? and (b) where do I go to get the information I need? Three main themes and sub-themes emerged in step 3: identifying information needs (country level, contextual, travel and safety, cultural), identifying information resources (nursing knowledge, key documents/ publications, key informants/ gatekeepers, key organizations/ institutions), and building relationships or trouble building relationships (communicating or ineffective communications, building trust or having inadequate trust, envisioning future or lacking forward progress). When Developing Understanding, participants asked themselves: (a) how do I make use of what I’ve found? and (b) how do I correct gaps in understanding? Nine main themes emerged in step 4: experiencing, figuring it out, internalizing, recognizing, clarifying (access, regulations, structure, trust, culture), defining (barriers, facilitators, existing efforts, needs & wants, safety & travel), sharing (background, challenges, experiences, feelings, perspectives), questioning (access, attitudes, interpretations, methods, ethics, social justice), and not knowing (preparatory needs). During the fifth step of the process Framing the Outsider Role, participants asked themselves: (a) how do I connect the pieces to fit the setting? and (b) how should I operationalize my role? Five main themes emerged in step 5: supporting (empowering, offering guidance, sustaining, not imposing), working together (collaborating, adapting, respecting, referring to locals, relying on insiders), Listening (two-way learning, seeking insider insights), following (national priorities/ needs, guidelines/ regulations, healthcare realities), and ineffective partnering (not listening, not working together).

Conclusion: This research generated a theory grounded in the realities of individuals’ experiences while partnering for nursing education in an unfamiliar setting. Concepts derived from interview data combined with researcher interpretations formed a theoretical framework that can guide individual nurses through the process of “Preparing for an Unfamiliar Setting.” Although the unfamiliar setting was defined as Ghana, Africa, concepts derived from analysis of participant experiences are broad enough to allow others to evaluate the model and transfer the grounded theory process steps to other settings.  

Analysis of participant experiences revealed the first 3 steps of the process occurred in advance of travel to the unfamiliar setting, while the last 2 steps of the process unfolded while participants were in the field in the unfamiliar setting. Developing Understanding was the process point that encompassed participants arrival at the setting, realization that they had not prepared as well as they thought they had, and their active seeking of deeper understandings from insiders. Findings revealed the necessity of including insiders as information resources during preparation.  Instances of ineffective preparation were also revealed across all steps of the process. In those instances, findings revealed that outsiders