Nursing Education: Changes to the Examination System of Nursing Education in India as Compared to UK

Introduction

This assignment discusses the changes that can be made to the present system within the nursing education specifically to the nursing examination system presently followed in India. The author of the assignment was a Nursing tutor in India and hence draws on personal and professional experience of the existing examination patterns. The author is presently a student at a University in the UK pursuing M.Sc in Professional Practice in Nursing and therefore explores the comparison to examination system in India to the assignment assessment in the UK for nursing students. The change includes, exposing Indian Nursing students to read widely and collect literature from evidence based practice and then write an academic essay rather than limiting them to learn from prescribed books and take up examinations.

It is imperative to state here however, that there has been a paradigm shift in the learning process, its goals as well as its outcomes. In the very beginning of the twentieth century, education was meant to only provide skills of literacy rather than enabling people to critically evaluate and think. It was focused on basic reading, writing and calculation. However, moving into the 21st century the higher aspects of literacy are more required so as to survive successfully in the contemporary world. Furthermore, the demand on skills required to be successful at the work place have dramatically risen (Bransford et al., 2000). While adjustments in the education system have been made in the developed nations such as the UK, India still follows the literacy pattern especially in the case of a professional course such as nursing (Iannone, 2012). The approaches to learning thus is now more formative with more emphasis given to practical learning rather than a summative format as is largely prevalent in the nursing education system in India. Here the system consists to memorizing information from textbooks and then writing the same in an examination which raises the literacy but does not contribute largely to the practice of nursing (Khadria, 2007; Iannone, 2012).

In India, the nursing examination pattern has undergone many a change since Vedic times until early 21st Century (Docslide, 2016). In these times, nursing was a skill based training given to those caring for the sick. It further evolved as a certified course to the current full-fledged degree level qualification status. Currently nursing graduates undertake University exams at the end of every academic year (Tiwari et al., 2013) in India. However this system has several drawbacks as the quality of nurses that emerge at the end of this type of examination based education system is vastly inadequate. This has even been termed as a major drawback within nurses from India (Meera, 2012). Evans et al. (2013) further states that the present nurse education through examination grossly lacks in skills development for emerging professional nurses. In this assignment the author will thus examine the management of such a change and how this change can impact the examination system in India.

Description of the problem

From the above discussed review of literature, it can be stated that the present education system needs to be reviewed. The instructors/ faculty are the vital players in any education, the nursing faculty in Indian examination system should be more of supportive in nature by inducing and inspiring the students to work in harmony and compassion while offering more formative, practical approaches to learning and assessment to aid the same. The authoritative behaviour of the faculty, does not allow the students to think for themselves to adequately care for patients. It has been stated, that the current examination system does not motivate and prepare the students to face organizational changes. (The National Advisory Council on Nurse Education and Practice, 2010) .

Change models

Change models refer to those that incorporate both the evaluation as well as those aspects of behaviour that are involved in resisting change (French et al., 2012; Sniehotta, 2009). There are many change models and theories that have been proposed. For the purpose of this assignment, models such as Lewin’s change theory (Lewin, 2013), Lippitts phases of change theory (Lippitt et al., 1958), Prochashasha and Diclementes change theory (Prochaska et al., 2013), theory of reasoned action and planned behavior (Southey, 2011), and Kotters change model (Kotter International, 2016) will be discussed and analysed.

All the change models here share similar characteristics. Kritsonis (2005) is of the view that the Lewin’s model is the most rational and also that which has set goals and an effective plan. Lippitt’s phase of change theory is most similar to the Lewins model and is an extension of the same. It contains five phases in all with the second phase before change and the fifth phase after refreezing that is mostly concerned with sustaining the change achieved. But in this scenario the theory focuses more on the change agent rather than the change occurring in itself. While the Lewins’ model analyses the two forces of driving and restraining, the DiClementes change theory is quite differentiated from the rest. This theory has a more cyclic quality to it as opposed to the other theories that are more linear in nature. This is the only theory thus far that takes into account the concept of relapse. A person can relapse back to the pre stage behavior at any of the stages of change behavior. This model affords for that and is evidenced wherein a person in the action stage can relapse into the contemplative stage and can further plan for action in the future (Kritsonis, 2005).

As for Kotter’s model of change, it is the most rigid approach as Kotter argues that all the eight steps are to be followed in the same order as presented and that if any of the steps merge then success may be compromised. This further implies that the steps are interdependent. Further to this it can be stated that some steps are not relevant to all contexts which is not the case with Lewins theory which can be applied to any scenario. The model is also not detailed enough to be incorporated in all cases.

Many enterprises have a concept for the sake of improvement. They employ the use of models for improvement. The most commonly used model is known as the Plan, Do, Study, Act model (PDSA) that is also known as the Deming cycle (Taylor et al., 2013). The model of improvement has been suggested to provide a viable structure and framework for the continuous improvement of work and the efforts thereby put in. There are three key questions that form the basis of this PDSA. The three components are also known as thinking components and include, what is one trying to accomplish?, how can this change be called improvement?, and what change can lead to an improvement? Curnock et al. (2012) are of the view that the stages of the PDSA test the changes so as to aid in the improvement of the quality and are most widely used. But even so, there remains a gap in how exactly this model can be applied in a practical setting which further warrants more research on the same so as to determine the rate of improvement and efficiency of the PDSA model (Curnock et al., 2012).

In view of this, the Lewin’s model of change is the model of choice for implementing the changes to nursing examination system in India. The changes will include changing the examination system so that the quality of nurses is better. The change is incorporating more examinations styles thatare more favourable to the practical aspects of patient handling would enhance the competency of nurses and empower them with practice oriented skills (Mella & Pinchin, 2008). This in turn increases the quality of nurses, which is much needed for nurses in India. Furthermore, the Lewin’s model has been irrefutable thus far for use in change theory and is still the model of choice as yet.

Kurt Lewin (1890 – 1947), a renowned psychologist, recognized as the “Father of Social Change Theories” has proposed numerous current models based on his work. Incidentally, Lewin’s model of change contains the necessary elements of the various models of change and has been deemed appropriate for incorporations both at the individual as well as governmental change (Kaminski, 2011). The three processes that are contained in this form of theory includes unfreeze, change and refreeze. Besides this, the Lewin’s theory contains a high level of attitude that aids the forerunner in the three steps. These are, changes that reach far and wide while reducing the intrusion on day to day organizational activities which goes to ensure that the change is permanent (Morrison, 2014). The three concepts that form the basis of this theory as per Lewin’s force field analysis include driving force, restraining force and equilibrium. Driving force is the directional energy that enables for the change to take place as desired. Restraining force forms the opposition to the directional force and equilibrium is the balance that is achieved between the driving force and restraining force. The equilibrium state does not bring about any change but rather is elevated or depressed as the requirement for the change is altered (Lewin, 2013). With respect to the current scenario, the driving force is the need for change in the examination methods to a more formative one as success in the world nowadays relies on it. The restraining force however, is insufficient funding and lack of training for the teaching staff.

Lippitt et al. in 1958 expanded Kurt Lewin’s Change Theory. The Lippitt’s, theory hence generated a seven-step one that emphasises more on the role and duty of the change agent than on the development of the change itself (Mitchell, 2013). The seven steps are analysing the problem, evaluation of the ability for change, evaluation of the resources and the inspiration behind the said change along with the change agent’s obligation to change and the change power and stamina. ( Project Zen, 2008; MacDonald, 2013). Additionally, the Lippitts theory enunciates that changes can only be constant if the change is applied to the system as a whole and not just to the affected portion. The theory further suggests that the changes are well ingrained in the face of two instances. The first instance is when an individual faces the same type of query in different ways and if the problem spreads to all adjoining processes (MacDonald, 2013). This theory when applied here, would imply the analysis of the current examination system, the ability to instil changes along with the feasibility such as cost and other resources and also the willingness of the boards to change the examination patterns. However, in this case the change must be applied to the education system as a whole rather than just the assessments.

The theory of reasoned action and planned behaviour states that individual performance of a given behaviour is principally determined by an individual intent to achieve that behaviour (Southey, 2011; Tlou, 2009). As applied to nursing examination patterns in India, the introduction of assignments and a formative assessment of the same can only be implemented if the nursing students want to see such a change. If the students themselves do not feel the drawbacks of the present examination system, then even a planned implementation of assignments during the course period will be bound to fail. Other factors also come into play here such as what the peers think. Even if one person wants a change, the social environment (such as peer opinions) has a large impact. As for planned behavior, the control over a skill set as well as a well presented opportunity is what will and can bring about such a change. (Sideridis et al., 1998; Aizen & Klobas, 2013 ; Özer & Yilmaz, 2011).

2.1 Initiating the Change

It has been suggested that when trying to initiate or embark upon change, it is always best to start on a smaller scale. This is the case even if a particular method was shown to be effective; it must first be tested in a new environment to measure the effectiveness of the system in that setting. This method of testing enables for the adaptations of newer and more innovative methods so as to incorporate change. Moreover, the organisation or system that requires changing, needs to be given adequate time to incorporate such a change and meet the recommendations needed for implementing such a change.

As per Teijlingen and Hundley (2001), it has been suggested that the conduction of a pilot study, and the results that they produce can enable the organisation and its leaders to make better decisions regarding the change that is needed to be implemented. In this scenario however, a pilot test maybe conducted for nurses for a semester in comparison with the regular assessment patterns followed. The results of this would then suggest the feasibility of implementing such a change and how the process may be imbibed.

Stakeholders

To analyse the view of the stakeholders it is imperative to first identify the stakeholders of any organisation or field. In cases where the changes of an organisation has impacts that are indirect, then the identification of such stakeholders are quite difficult. Stakeholders form a very important aspect of any organisation as they play a key role in the success of an organisation and the change. The benefits of identifying the stakeholders lie in their deciding capacity of whether or not a change can be taken forward. The success of the change too depends upon them as they offer the overall views of the changes. Therefore for successful implementation of the change, one needs to identify the stakeholders, understand how important they are, what changes they want to see and what influence they will have overall and what all can they be involved in (García et al., 2012).

The stakeholders in this situation of nurse examination in India are identified as nursing students, Universities, and nursing colleges. Additionally, parents too take on a key role as stakeholders.

Change agents

A change agent may be defined as any individual or a group of individuals that take up the process of change in an organisation. Lunenburg (2010) states that, they can be managers of the organisation or even the employees who will be hired or delegated to oversee the change process as a whole. Most organisations hire external change agents for the same purpose mainly as these agents will not be bound by the companies’ values, rules and operations and thereby can oversee and ensure the change with more freedom. They can also offer a solution from a varied perspective. The main disadvantage of hiring a change agent is that they lack knowledge on the history of the organisation and fail to understand the operations as well as the employees and their role. However, Owen and Dietz (2012) are of the view that the type of change agent that can bring about such a change is yet to be determined (Lunenburg, 2010; Owen & Dietz, 2012). Lunenburg (2010) further enumerates the types of change agents to include, the outside pressure type, people change technology type, analysis of the top type, and organisational development type (Lunenburg, 2010).

Owen and Dietz (2012) state from their research that the role of change agents include, consulting, training and research. In the role of the consultant, the organisation grants access to the employee to the outside workings so that he can derive a solution by solid analysis of the data. For the role of training, the manager who acts as the change agent trains the employee on how to use the data to effect the necessary change. For the role of research, the manager will train the employees on how to sustain the change and also design a change strategy not only for the present scenario but also for future changes if required. Other aspects of change agentry include successful change agentry characteristics that are, hemophily, empathy, linkage, proximity, structuring, capacity, openness, reward, energy and synergy (Owen & Dietz, 2012).

Barriers and drivers of change

Moreover, the nursing examination in India lacks in the aspect of conducting examination for the nursing candidates in dealing with patients adequately.. The present nursing examination system offers less room for students to recognize their actual duties and responsibilities pertaining to their profession. This in turn is suggestive of the lack of perception from the teaching faculty which forms a barrier to the change. (Heidari & Norouzadeh, 2015).

Indian nursing examination system stands for its quality in study materials but lacks in offering access to nursing students the facility of self- research and learning. This may be due to the insufficient funds to meet the cost for training the current staff for formative assessments. The nursing education institutions therefore, rely on the Indian Nursing Council for making even smaller changes to the assessment system. This scenario is because of the monotonous authoritative order of the nursing education system in India. The change advocated by certain private medical institutions in India who are associated with universities in the UK have attempted to bring in a change in the assessment pattern but the Indian nursing Council did not approve the same and hence remains un-implemented (Gulavani & Shinde, 2014). It would be more beneficial for a nursing graduate from India if the Indian Nursing council and the State Nursing council adopt new methodology in teaching nursing candidates and also in assessing their level of understanding as of the UK.

The duties and responsibilities of nurses taught through the examination system differ from what is learnt through the examination . Nursing students should be given more practical examinations to handle all roles and responsibilities to satisfy the patients’ needs and requirements and also to improve the applicability of what was learnt. Initiatives should be adopted to provide additional examinations to assess care and cure of patients both emotionally and clinically. The shift from looking at nursing as an occupation to nursing as a profession is required, which is the key to making changes to the examination system. (Gulavani & Shinde, 2014).

Before implementing a new initiative, it is therefore imperative to assess the drawbacks of the present examination system This analysis will help to identify the key areas of obstacles which hinder the change required. The higher officials of examination system should acknowledge the need for change for a better development and also they should take necessary steps to clear the gap. Awareness and motivation should be advocated to insist the need for a change to the present scenario to offer better assessment practices.

2.2 Lewin’s Three Phase Change

As aforementioned, Lewin’s model advocates that the recognition of three stages for a successful implementation of the change (NHS North West, 2011). The change in this case refers to the incorporation of assignment writing systems to the existing examination system in India. The change however, can be brought about by the Lewin’s three phase change. The present system of nursing examination system needs to be unfrozen and changed by introducing assessment by assignments based on literature review so that the nursing graduate may be better equipped for real time situations. The same can then be refrozen by the policy makers. Each of the phases of change has been elaborated as below.

Unfreeze

The phase of unfreezing is the first step in Lewin's Model. This corresponds to the motivation to change as it is deemed that changing the present perception to a scenario is first step to changing the practices themselves and making other aware that there is a need for a change (Sarayreh et al., 2013).The team members are involved in planning for the change in order to maximize the outcome of the change management. For the scenario of the nursing examination system in India, the current examination process needs to be re-examined and unfrozen. The motivation is drawn from the various drawbacks that are stated in the current examination practice for nurses in India (Meera, 2012). Although there are certain benefits with the nurse examination system in India (Robinson & Griffiths, 2007), the need for a change as of the United Kingdom's assignment system must be emphasised by the Indian nursing council, heads of nursing institutions, and also should motivate and create awareness among the nursing students in India to recognize such a need of change. However, in India, the major drawback of the nursing students are the lack of self-reading (outside of the textbooks) and then analyzing while subsequently applying them within the nursing practice area. Yet another drawback is the lack of correlation between theoretical instructions and practical training (Meera, 2012). These aspects need to be proven unsatisfactory and therefore needs to be unfrozen to instil a change. While the introduction of assignment writing as a precursor to closed book examination could be implemented in few states of India on a pilot basis before applying uniformly in all the nursing institutions across India (Robinson & Griffiths, 2007).

Change

Following the Unfreeze stage, the “change” process is where members invent new ways of doing things. The time scale between unfreeze to change process is lengthy and forms the main part of Lewin's change model. Only if the need and motivation for change is communicated, the change can be implemented and set in motion. Further to this, people are also empowered to promote change with good communication. People are urged to embrace newer and better ways to work while also embracing different attitudes and behaviours. After this, a process of identifying problems takes place so that a smooth implementation of change is enabled. At this stage flexibility is vital for the planning and implementation process (NHS North West, 2011).

The change phase is initialised after resolving the prevailing uncertainty of the unfreeze stage. In this stage the uncertainty is resolved and the change is put about in action. It has been deemed that identifying the outcomes of the change is most important in determining the effects of change. The challenges to implementing change remain that not all employees will follow what is required to implement change. Likewise it has also been stated that for the implementation of the change, clear cut information is required to be provided so that this change can be successful (NHS North West, 2011; Sarayreh et al., 2013). In this case, to implement change to the nursing examinations system is to introduce writing assignments that are more practical in nature, involving basic literature search that is formatively assessed by the teachers. This could lead to an increased knowledge of current practices following which a closed book examination may take place (Willis Commission, 2012). This process of change would take a reasonable time to be embedded into the system by nursing students and their teachers.

Refreeze

Refreeze refers to the organisations regaining stability after the change process and also when the benefits of the said change are recognised. This further fuels installation of confidence for the next process of change that is inevitable. Additionally, on an individual level, recognition is required. This can be in the form of praise, rewards or other types of reinforcement by the managers. Here, until the change is completely integrated into the system, it cannot be frozen (Sarayreh et al., 2013). The changes to the examination system advocated needs to be adopted by the universities and nursing institutions in India. Here the formative assessments may be carried out throughout the academic year with the closed book examination held at the end of the year. This ensures changes to the learning while also maintaining the existent system to ensure applicability of the highest standard. Further, adopting this strategy to freeze the change can ensure that the system does not lapse and continues to be in place for the future as well, thereby supporting the desired change to make certain that the change is neither temporary nor lost.

Conclusion

It is thereby clear that the Lewin’s model of change suits the necessitated change in the case of nursing examinations in India. In this context, it was observed that the main reason behind such a change is the need for more developmental learning rather than just literacy aspects of the same. This is due to the demand on such capabilities coupled with valid certification that drive success in the professional world. While several models of change were identified during the course of the essay, all were based on very similar lines. The main difference however lay in the execution of the change. The Lewin’s model in this case embraces all the aspects for instilling the change which includes assessment for change, the change itself as well as the sustainability and reinforcing such a change. In addition to this, the driving and opposing forces for such a change to be instilled may also be identified. This makes the Lewin’s model, the change model of choice in this context for changes in the nursing education in India.

In conclusion, the nursing examination process in India as a whole can benefit from the implementation of the assignment writing patterns for enhanced learning in conjunction with the system currently in place, as the students will then have adequate theoretical as well as practical knowledge as opposed to the largely theoretical base that currently exists. It will also pave way for more and more Indian nurses to gain international recognition both on the academic as well as the skill fronts.

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