Exploring nurses' experiences of social media and in-person educational interventions for professional development: a qualitative study

As part of a trial [25], a qualitative study was conducted to explore nurses' experiences of social media and in-person education approaches. The study used the directed content analysis approach. The goal of a directed content analysis approach is to validate or extend conceptually a theoretical framework or theory [26]. Existing theory or research can help focus the research question and it can help researchers begin by identifying key concepts or variables as initial coding categories. This approach was employed by Hsieh and Shannon in 2005 [27]. Content analysis using the directed approach employs a more structured process than in a conventional approach [28]. As such it is appropriate to use existing theories or prior investigations about the phenomenon under study.

Participants included nurses working at relevant hospitals. Inclusion criteria were: at least one year of work experience in nursing, previous experience of receiving social media, and in-person education. The study was approved by Tarbiat Modares University of Ethics Committee for Health Research Ethics (IR. TUM. REC. 2017/545), and all participants provided written consent. As well as, the researcher reminded commitment to ethics in research, such as secrecy, preservation of anonymity, permission to leave the study, and interruption of the interview if desired.

The data were collected based on individual semi-structured interviews [29, 30]. The Interviewees in this study were nursing personnel. The recruitment of participants for the interviews was based on purposive sampling. Decisions regarding the number of individual interviews were determined by data saturation [31]. The original interviews were conducted by the main researcher (SSK) between August 2017 and March 2018 and lasted between 35 to 50 min. All the interviews were conducted in a private room. In the first, the researcher explained the study goals and reasons for doing the research to the participants. To ensure consistency, each interview followed the same semi-structured format, using an interview schedule consisting of open questions, all interviews were recorded and transcribed. The interview guide consisted of open-ended questions based on subcategories of the enabling, administrative, and policy factors of PRECEDE model to allow respondents to fully explain their own experiences. The questions such as "What do you think about social media and in-person education approaches?/ Which approach is in line with hospital policies?" Likewise, they were asked to express their experiences and indicate their preferences.

The study used the directed content analysis approach. The data analysis process was carried out simultaneously by collecting data [32]. Semi-structured interviews were tape-recorded, transcribed verbatim, the transcript read several times, and parts of the text highlighted, that were relevant to the study goals. The highlighted passages were broken up into semantic units. Then investigators identified meaning-units from each transcript and performed initial coding according to the participants' phrases. Any text that could not be categorized with the initial coding scheme was given a new code. Initial codes were identified by at least two co-investigators, and codes were then categorized according to similarities and differences [31]. An initial analysis created 20 excerpts (sections of text). The data were independently coded by another researcher with in-depth knowledge to explore consistency. The second researcher also created 22 extracts. Transcripts, codes, and categories were read several times by various members of the research group to exhaust identifiable major themes. During this process, data were reduced from text to codes and categories. Based on the type and breadth of a category, researchers identified subcategories with subsequent analysis. When the coding assignments were done for both researchers, have reviewed the three assigned codes from expected outcomes, such as presentation and adoption of education, effectiveness, and efficiency of education, policymaking, and facilitators for education. All coding steps for interview passages were also managed using the MAXQDA 10 editing software.

The evaluation criteria for establishing the trustworthiness of qualitative data were also considered [28]. There was constant comparison within and across categories and across interviews where each code or category was checked against the rest of the data to establish and refine categories that reflected the nuances of the data [33].

Credibility is the equivalent of internal validity in quantitative research and is concerned with the aspect of truth-value. One of the strategies to ensure credibility is member checking [34, 35]. All transcripts of the interviews were sent to the participants for feedback. Further, halfway through the study period, a meeting was held with those who had participated in the interviews, they corrected the ‘wrong’ interpretation.

Dependability, related to reliability in quantitative terms, occurs when another researcher can follow the decision trail used by the researcher [36]. The text of the interviews, the relevant codes, and the emerged themes were sent to two researchers outside the study who were familiar with qualitative research. Outside researchers examined the research process and the data analysis to ensure the findings were consistent and could be repetitive. Then their complimentary comments were used in the analysis of the data. Further, at a meeting, we discussed the interpretation and presentation of the research findings of uncomplimentary until achieved a common result. As well, we used peers to participate in the analysis process to enhance the original findings.

Confirmability that the findings were based on participants’ responses and there were not any potential bias or personal motivations of the researcher [34]. We have tried to use the participants’ narratives and words rather than potential researcher biases. To establish confirmability, the researcher provided an audit trail, which highlighted every step of data analysis that was made to provide a rationale for the decisions made. This helped establish that the research study’s findings accurately portrayed participants’ responses.

The original data collection comprised a series of interviews with a sample of 15 project participants. Most were female (n = 11) and their age ranged from 27 to 52 years old (40.6 ± 8.9). They have been employed as a nurse for at least one year (15.33 ± 9.2 years). Participants included nurses working in hospitals affiliated with Mazandaran University of Medical Sciences. The characteristics of participants are presented in Table 1.

The study obtained 3 themes, 9 categories, and 22 sub-categories (Tables 2, 3).

Approaches to nursing education and its adoption in the health system.

Nurses acknowledged that most of the time, in-person education is not provided by an education specialist. So, this theme was derived from performing the program by the staff working in the hospitals, such as the educational supervisor, head nurse, or different sectors' nurses. In this case participant 4 (head nurse, age range 50–60) said:

“Some of the time, education is provided by the staff or nurses. The supervisor teaches head nurses and the head nurse educates sector nurses in the form of a category education to the category. Since different departments need to have internal education, some education will be provided by nurses of the same department as a conference. But due to the bustling ward and a large number of patients, not all colleagues can attend the training at the same time. If education is implemented through the app or social media, then there is no need to provide education by nurses or other staff.”

- Skill Learning: The effect of education on increasing knowledge, practice, and skill was identified, and the role of practical education in promoting behavior skills was emphasized. In this regard, participant 3 (nurse, age range 20–30) said:

“The system thinks in-person education is better than social media. Because in-person education can provide practical examples, nurses can ask questions and issues related to the subject of education. Also, pre-test and post-tests are taken in an in-person education, and the nurse's performance is evaluated. While the system can be designed for education via social media in such a way that contains educational videos practical examples in the form of videos, photos, animations, etc. And the educational supervisor monitor how many percentages of the staff used the program and training. As well, evaluate our knowledge and performance through the website."

- Interactivity in education: Interactivity in learning is viewed as a socio-constructivist process and can be communicated among content and participants [37]. Most participants had referred to interactivity in In-person education because In-person education can prepare an adequate situation to ask questions and stimulate communication between participants. Since nurses have received educational content via CD or pdf files sometimes, they thought education via social media is one-way and interactive communication is not possible. So participants emphasized two-way communication in education and its interactive social media. Participant 15 (nurse, age range 40–50) said:

“When staff gets together, it is very good. Because they can be exchanging ideas. Also, there are a lot of questions for each of us, and maybe at that moment don't work the memory to ask. Persons can be actively participation in education and do some practical work. But I think in interactive social media, we can talk and express our opinions."

- Remembrance for restoring of information:

One of the nurses' concerns was the oblivion of the content learned over time. Most participants believed that an appropriate education program should be repeated over time, otherwise it will be forgotten. In this regard, participant 1 (nurse, age range 50–60) said:

"One of the disadvantages of in-person education is receiving little information and content and it only is at one time and the information learned does not repeat over time. Thus, the content learned will be forgotten. But I think one of the benefits of education through the app or social media is receiving a lot of information and content at different times, and also reminding and repeating the content. If we forget about it over time, we can refer to the app."

Health care policy and facilitating pathways for nursing education.

This theme was extracted from five sub-categories as follows:

- The importance of motivation in education:

Considering that educational programs are part of hospital accreditation measures, lack of motivation, and disinterest by nurses, also lack of support and reward by managers prevent nurses from participating in face-to-face education. Thus, these factors lead to not attending the class on time, leaving the class out earlier, lack of taking notes, and not paying attention to education. Participant 5 (nurse, age range 30–40) on the role of material and spiritual motivation said:

"If the education program is out of work hours, nurses don't like in-person education and prefer to receive training virtually. Because the time of education will not be considered as a part of our overtime hours. The encouragement certificate for work promotion was not considered. While the certificate can have a positive impact on the annual performance appraisal."

- The time limit for easy educational access:

Getting easier to access education and having no time limits are basic nurses’ rights. But based on the analysis obtaining in-person education and its access was less possible for nurses. In this regard, participant 9 (nurse, age range 20–30) said:

“When only one date is set for an educational program, maybe we can't attend. For example, perhaps there were many patients at the same time and there aren't many nurses in the sector. Certainly, we cannot participate in education. It is better to set a few dates for an education topic so that nurses can participate in different dates or send via social media. In this way, we can read the contents when the unit is not crowded or at rest time. "

Participant 11 (nurse, age range 30–40) said:

"I think the advantage of social media is most people can access this type of education and share information. We can use this program whenever we want, and we don't have to go to the hospital from home. There is no time and space limit. Even at rest, at work and home, at any time of day, we can use this type of education. We can also have access to a lot of educational content."

- Lack of staff: Most participants referred to the lack of staff in different sectors. They said these factors lead to working pressure. Working pressure and high workloads are seen as the main barriers to attending in-person education programs. Therefore, nurses didn't have enough time to attend in-person education and expressed their tendency to use educational programs based on social media. In this case, participant 2 (nurse, age range 30–40) said:

"We are faced with a lack of staff. So that one person should work instead of two or three persons. Thus, the load of our work is very high, and we have to tolerate a lot of pressure."

- Lack of funding for education:

Data analysis found one of the barriers to in-person education is the cost of education implementation. Thus, one of the most important concerns of education executives is the financing of education costs (such as the payment of the educator, catering fees, educational equipment, and adequate space for education). Participant 6 (nurse, age range 30–40) said:

"One of our educational problems is a lack of funds. The hospital's operating personnel says you should find a sponsor for the educational program. In-person education is economically not desirable because of the commute and payment to the educator. But education through social media is just an app that's installed on the mobile phone and does not require commuting, educator fees, or catering, even it has not needed a place for education."

- Program Failure over time:

The data showed some factors that lead to program failures over time. Such as lack of suitable education space, lack of proper education, no having trainer or educator. In this regard, participant 13 (nurse, age range 30–40) said:

"Perhaps faculty members educated their students in the hospital and not at college or maybe there was a retraining class. So the educational supervisor will coordinate with the unit of education a few days before the education. But, sometimes the education program maybe to be canceled due to a lack of appropriate location or space."

The main limitation of our study is related to data collection. Some nurses were reluctant to participate in the study because of their high workload and lack of time. To overcome this limitation, the researcher asked nurses to choose the time of the interview according to their working conditions. Other limitations of this qualitative research include the following:

The interview process was time-consuming.

It was not possible to reach all the participants.

The interview required the consent and willingness of the respondent, the patience and perseverance of the interviewer.

Sometimes, participants were reluctant to express explicit opinions.

Despite its limitations, our study has had several characteristics of value. Firstly, our results provided a platform from the nurses' standpoint to evaluate educational approaches. As well as, it is recommended policymakers assess resources, development, and allocation of budgets, organizational barriers, and coordination of the program according to target groups.