1 Iva Lazinica
2,4 Mediana Županović*
3,4 Dragan Šijan*
1 Cardiology department – Coronary care unit, General Hospital of Šibenik-Knin County, Šibenik, Croatia
2 Department of Internal Medicine, General Hospital of Šibenik-Knin County, Šibenik, Croatia
3 Specialist Ophthalmology Practice Nikolina Basioli, Zadar, Croatia
4 University of Zadar, Department of Health studies, Nursing, Zadar, Croatia
* Graduate student at University of Zadar, Department of Health studies, Nursing
Article received: 01.02.2023.
Article accepted: 31.03.2023.
Author for correspondence:
Iva Lazinica
Cardiology department – Coronary care unit
General Hospital of Šibenik-Knin County, Šibenik, Croatia E-mail: iva.lazinica024@gmail.com
https://doi.org/10.24141/2/7/1/1
Keywords: specialization, nursing, attitudes of nurses
specialized field as the main motive for specializa- tion. A statistically significantly higher number of participants expressed their intention to continue their education in the future and progress profes- sionally. The limitation in this intention stems from the fact that the majority of participants are not fa- miliar with the specialization program, even though their attitudes support specialization.
Chronic non-communicable diseases are increasing all over the world. In Europe, according to data from the World Health Organization, 86% of mortality and 77% of disease burden are caused by chronic non- communicable diseases.
The population of our country is counted among the “old population” with a high proportion of people over 65 years of age. The total average of life expec- tancy increased from 71 years to 77 years. According to indicators of mortality and morbidity, non-chronic infectious diseases prevailed in Croatia before the pandemic, which was the cause of mortality in 93% of cases. For example, cardiovascular heart disease, as a leading chronic non-communicable disease, al- though on the rise, has seen a decrease in mortality, thanks to advancement in treatment and health care, as well as primary, secondary and tertiary preven- tion (1). Nursing means providing health care inde-
pendently or in a team to all age groups, individuals, families and communities, sick or healthy in all cir- cumstances (2).
Thirty thousand employed nurses make up more than 40% of all employed health workers. Howev- er, the continuous shortage of nurses in Croatia is manifested by a ratio of only 6.3 nurses per 1,000 inhabitants, which is below the European average of 8.4 nurses (3). The number of nurses per capita is the highest in Denmark, Finland, Switzerland and Iceland, but it should be noted that one-third of that number are health assistants to nurses (4). The shortage of nurses in Europe has consequences on the quality and continuity of care for patients, and puts the nurses themselves at serious risk due to work overload. Studies conducted in 300 hospitals in nine European countries show that heavy nursing workload is associated with a 7% increase in the rate of death of patients after surgery within 30 days, and a 10% increase in bachelor’s degrees in nursing reduces mortality by 7%. These connections imply the importance of bachelor’s degree education for nurses, and clearly show that the number of bach- elor’s degree nurses in the ward means high patient safety and satisfaction (5).
In Croatia, the basic education of nurses consists of a five-year high school education, and a higher level of education is obtained by completing an undergradu- ate professional or university nursing programme, and/or a graduate university nursing program. In the Nursing Act of the Republic of Croatia, additional training of nurses is carried out in cases where the scope and complexity of work and expected results require additional education, or specialization in a certain area of health care. Duties and competencies of a nurse depend on the level of training. Compe- tences of nurses with completed specialist training and post-graduate university programs are deter- mined by the list of output competencies/learning outcomes in accordance with the regulations on spe- cialist training of nurses (6). The joint mandatory part of the undergraduate university and professional nursing study program is aligned with the provisions of Directive 2005/36/EC of the European Parliament and the Council on the recognition of professional qualifications (7).
The Ministry of Health adopted the Rulebook on the specialist training of nursing bachelors in the field of emergency medicine, as the first specialization in nursing. The intern is considered to be a nurse with
at least a bachelor’s degree in nursing, who is em- ployed for an indefinite period of time in a health institution. The annual need for specializations of healthcare workers is determined by a decision of the minister. The specialization will last one year, the theoretical part of the specialization will be carried out at universities, and the clinical part in author- ized health institutions. After passing the specialist exam, the title “specialist in emergency medicine” is obtained (8).
The complexity of treatment in the acute and chronic phase of the disease requires specialized healthcare in order to ensure quality outcomes for the patient.
Specialist nurses are not a novelty in the world. In Great Britain, there are various specializations in nursing, which are divided into two groups: Specialist Community Public Health Nurses SCPHN and Nurse Practitioner. The requirement for specialization is a bachelor’s degree. The education lasts 1 year full- time, which includes 50% theoretical and 50% practi- cal part, and is focused on clinical health care, leading and managing health care in the clinic. In addition to specialist areas such as hematology, oncology, sur- gery, etc., there are also narrow specializations such as specialist nurse for patients with Multiple Sclero- sis, etc. (4).
The aim of the research is to show the views of nurs- es of the General Hospital of Šibenik-Knin County re- garding the need for additional education in nursing, the perception of the importance of specialist educa- tion, motives and intentions for specialization. The level of information of nurses about specialist educa- tion in nursing is shown.
The aim is also to determine whether there are dif- ferences in the attitudes of nurses with regard to the level of education, the length of service in the nurs- ing profession and the position they hold. In the pa- per, we stated two hypotheses about the attitudes of nurses in the General Hospital of Šibenik-Knin County:
Hypothesis 1: The attitude of nurses towards spe- cialization differs according to the level of education.
Hypothesis 2: The attitude of nurses towards spe- cialization is statistically significantly related to the workplace of the participants.
The research was conducted by means of a struc- tured survey questionnaire with closed-ended ques- tions. The questionnaire used in this research was compiled using the questionnaire from the article “A new system for nursing specialization”, the use of which was approved by the original authors. It is en- titled “Opinions of nurses on the importance of spe- cialist training”. The research was conducted anony- mously through an online service available through the Google platform, and anonymity was ensured in such a way that the contact information of the par- ticipants (e-mail addresses) could not be linked to the answers of individual participants. The target popu- lation for the research was nurses, and the research was conducted on a sample of N=146 nurses from the General Hospital of Šibenik-Knin County. Data were collected individually and online. The conduct of the research was approved by the Ethics Commit- tee of the General Hospital of Šibenik-Knin County on October 3, 2022. The research was conducted in the period from October to November 2022.
Numerical values are presented using methods of descriptive statistics, where the arithmetic mean is used as the mean value, while in case of deviation of numerical values from the normal distribution, the median is used.
The existence of a connection between certain vari- ables is determined by the correlation coefficient and the existence of a statistically significant difference by the Chi-square test as method of inferential sta- tistics. Due to failure to meet the conditions for the ANOVA test, the Kruskal-Wallis test was used.
The analysis was done in the statistical software SPSS 25.
Most of the participants were female N=142, while N=4 participants were male.
According to age, it can be determined that 1 re- spondent is under the age of 20, while the largest number of participants is between 21 and 30 years old (n=39) and between 31 and 40 years old (n=39).
The most common level of education of nurses is a completed secondary vocational education (n=82). A proportion of n=48 nurses have a bachelor’s degree in nursing, while a total of n=16 nurses with a mas- ter’s degree took part in the research.
The data in chart 1 show that the largest number of participants have a working experience of more than
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Chart 1. Participants by level of education
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Chart 2. Participants according to length of service
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Chart 3. Participants by workplace
Table 1. Participants’ attitude towards additional education | ||
Claim | AS | SD |
Further education and training of nurses affects the well-being of patients and the improvement of health care | 4.34 | 1.00 |
Nurses have a rightful place according to the level of education in the business hierarchy | 2.60 | 1.23 |
By specializing in a certain area, a nurse would be much more successful in providing services within the scope of specialization | 4.49 | 0.84 |
Any additional education of a nurse should be monetarily valued according to the law | 4.84 | 0.57 |
I value a more experienced nurse with less education more than a more educated nurse with less work experience | 3.70 | 1.22 |
The process of training nurses is easy and simple | 2.06 | 1.13 |
Already in high school, it should be possible to become a specialist in a specific area of work for a nurse | 3.06 | 1.46 |
I believe that working in the anesthesiology department requires additional specialization of nurses as in highly developed countries | 4.61 | 0.73 |
*AS=arithmetic mean; SD= standard deviation
20 years (n=57), while only one respondent has a working experience of up to one year.
The largest number of participants are employed in the hospital department (n=78), while only 9 partici- pants are in the emergency clinic (n=9).
Participants expressed their attitude towards ad- ditional education by expressing their agreement with certain statements about specialist education using a Likert scale from 1 to 5, where 1 means ‘do not agree at all’, 2 ‘do not agree’, 3 ‘neither agree nor disagree’, 4 ‘I agree’ and 5 ‘I completely agree’.
Participants expressed the highest level of agree- ment with the statement “Any additional education of a nurse should be monetary valued according to the law”, where a high level of agreement with the statement was determined at 4.84 (SD=0.57), while the statement with which the participants least agreed was “The process of training nurses is easy and simple” with a low average score of agreement with the statement of 2.06 (SD=1.13), which cor- responds to the qualitative statement “disagree” on the Likert scale.
The way in which participants perceive the contribu- tion of specialization to the nursing profession was
examined through a closed question, and partici- pants could choose between one or more pre-deter- mined answers (chart 4).
The largest number of participants (n=50) believe that specialization contributes to the nursing profes- sion in a way that increases the quality of service in the healthcare system. Participants (n=48) rec- ognized the reduction of the possibility of error as an important contribution of specialization in nurs- ing, and n=33 of them believe that specialization leads to greater loyalty to work and a higher level of employee satisfaction. The number of participants who recognized the growth of self-confidence due to training as an important contribution of speciali- zation is n=13. To summarize, a total of n=98 par- ticipants consider the improvement of the quality of services and the reduction of errors to be important contributions of specialization and understand the contributions from the patient’s point of view, while n=46 participants recognized the contributions that specialization brings to themselves.
Following the perception of the contribution of spe- cialization for the participants, chart 5 highlights the basic motives when making a decision on specializa- tion. Participants could choose one or more of the
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Chart 4. Participants according to their perception of the contribution of specialization to the nursing profession
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Chart 5. Participants according to motivation for specialization
pre-determined answers (higher level of knowledge, desire for advancement, higher salary, challenges and social reputation).
The data in Chart 5 shows that a total of n=65 par- ticipants are motivated by the desire for a higher lev- el of knowledge in a narrowly specialized field, and as many as n=42 participants are motivated by the desire for advancement and a higher salary (n=32). Challenges and reputation in society are less preva-
lent motives for specialization in nursing. Challenges are motivation for n=6 participants, and reputation in society for n=1 participant.
Chart 6. shows the intention to continue education in the future
According to the intention of continuing education in the future, it can be determined that the larg-
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Chart 6. Participants according to their intention to continue their education
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Chart 7. Participants regarding their familiarity with the specialization program
est number of participants have this intention (71; 48.63%), while 33 participants (22.6%) do not have this intention. The need for further reflection on the decision to specialize in nursing was expressed by 42 participants or 28.77%.
Chart 7 shows the extent to which participants are familiar with (informed of) the nursing specialization
program. Participants could choose one of the two answers; I am informed and I am not informed.
The data in chart 7 shows that the number of partici- pants who are informed of specialization programs is lower compared to participants who do not have available information about specialization programs. Thus, the number of informed participants is n=32 or 22%, and the number of those who do not have infor-
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Chart 8. Participants according to support of specialization
mation about specialization options is even n=144 or 78%.
Chart 8 shows the results on the level to which par- ticipants support the specializations of nurses.
The largest number of participants support the spe- cializations of nurses (n=123; 84.83%). A share of 13.1% of participants expressed restraint, and only n=3 or 2.07% of participants do not support the spe- cialization of nurses.
Chart 9 shows the views of participants on the po- tential problems of implementation of specialization within the profession. These potential problems can be divided into three key categories, which are prob- lems related to the organizational structure or or- ganization of the department. Such problems include the reduction of the possibility of employee migra- tion between different departments and the limited authority and responsibility of nurses. The second category of problems actually represents motives for non-specialization (the impossibility of practicing education in a working environment and the unavail- ability of certain specializations). The third category of problems can include the potential negative per-
ception by the professional team about nurses who refused specialization.
The most significant organizational problem arising from the implementation of specialization is the re- duced possibility of migration within the department, according to the view of n=37 participants, and n=31 participants recognize limited powers and responsi- bilities as a problem in the implementation of spe- cialization. When considering the motives “against” specialization, it should be noted that n=42 partici- pants believe that they will not be able to apply the acquired skills in a working environment, while n=27 participants are of the opinion that the unavailability of certain specializations is a problem when imple- menting specialist programs. Only n=9 participants consider the negative and unfavourable position of nurses who refused to specialize to be a problem.
H1: The attitude of nurses towards specialization dif- fers according to the level of education
The presence of a statistically significant difference was not established, so hypothesis H1, which as-
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Chart 9. Participants according to potential problems of implementation of specialization within the profession
Table 2. Correlation coefficient: connection between nurses’ attitude towards specialization and length of service | ||
Length of service | Attitude towards improvement | |
Length of service | 1 | |
Attitude towards improvement | -0.2376 | 1 |
p value=0.075
sumes that the attitude of nurses towards speciali- zation differs according to education, is rejected.
Based on the data in Table 2, it can be concluded that there is a negative correlation or an inversely proportional relationship between the length of service and the attitude of nurses towards training. When evaluating the strength of the relationship be- tween the variables, a result of 0-0.25 is considered a weak correlation, and the obtained result of -0.23 points to a correlation of a negative direction and a weak correlation between the length of service and the attitude towards improvement, in such a way that a longer length of service is associated with a lower level of positive attitude towards improve- ment. The empirical p-value of 0.075 is higher than the threshold p-value of p=0.05, and the hypothesis of a statistically significant relationship between the attitude towards specialization and length of service is rejected.
H2: The attitude of nurses towards specialization is statistically significantly related to the respondent’s workplace
Hypothesis 3 was tested by calculating the correla- tion coefficient in order to determine the connection between the attitude of nurses towards specializa- tion and the workplace where the respondent is em- ployed (outpatient clinic, emergency clinic, hospital ward, day hospital, intensive care unit and operating room) (Table 3).
Based on the data in Table 3, it can be concluded that there is a negative correlation or an inversely proportional relationship between the workplace and the attitude of nurses towards training. When evalu- ating the strength of the relationship between the variables, a result of 0.25-0.60 is considered a mod- erate correlation, and the obtained result of -0.30 points to a correlation of a negative direction and a moderate strength between the workplace and the attitude towards improvement, in such a way that the attitude towards improvement is more present in subjects employed in day hospitals, in hospital wards, intensive care units and in the operating room compared to subjects employed in outpatient clinics and emergency clinics. Since the obtained p value is
0.55 higher than the threshold p value of p=0.05, H3 is rejected.
In terms of the structure of the participants, most participants were females, with mostly secondary education, younger (21-30) and middle (31-40) age groups, the largest number of whom have 20 years of experience. The largest number of participants were employed in hospital wards, and among the participants there was a smaller number of emer- gency room staff.
Specialist programs in nursing have an important role in raising the overall quality of medical care, because through nursing care and the educational and advi-
Table 3. Correlation coefficient: connection between nurses’ attitude towards specialization and workplace | ||
Employees by individual workplaces | Attitude towards improvement | |
Employees by individual workplaces | 1 | |
Attitude towards improvement | -0.304131124 | 1 |
p value=0.55
sory role in certain branches of medicine in which they specialize, they can significantly and positively influence the results of health care (9). The above statements are in accordance with the results of the conducted research, considering that the largest number of participants perceive that the improve- ment of the quality of service and the reduction of the possibility of error are the most significant ben- efits that can be obtained by the implementation of specialist programs in nursing. The motives of the majority of the participants are consistent with the view that specialization contributes to the increase in the quality of services, and the majority of partici- pants emphasize the desire for narrowly specialized knowledge as the basic motive for specialization.
The need for specialization in nursing is recognized at the international level, but also in Croatia. Regard- ing the participants’ knowledge of the specialization program, we note a negative trend in which a large percentage of the participants are not familiar with the possibilities of specialization. The specialization program itself in the Republic of Croatia was intro- duced in 2009, which provides that nurses with a completed undergraduate level of education can enrol in the specialization. The stated claims can be supported by the results of the conducted research. Namely, a large proportion of participants expressed a firm intention to continue their education, and the proportion of participants who are thinking about the option of further education is not negligible either, but the level of information about specialist pro- grams they have is very low, as the results show. The observed disparity between the intention for further education and the level of information about the pos- sibilities of further education in nursing is crucial to bridge through the organization of educational and promotional activities among the target population of nurses.
The majority of participants supported the state- ment “By specializing in a certain area, a nurse would be much more successful in providing services within the scope of specialization”, as well as agreed that specialist education within the profession is neces- sary. As the health sector systematically develops and evolves, so does the constant need for highly qualified nurses. The outstanding results of the re- search confirm that specialist programs for the edu- cation of nurses are also a reflection of the growing need for very specific knowledge and competencies of nurses (10).
Bagat (according to Ivanov) conducted research in which he examined the motivation of healthcare workers in Croatia, which included six factors of mo- tivation. A very small percentage of participants be- lieved that the institution where they are employed implements employee motivation, and the awards that would be used to evaluate motivation were in terms of further training and education. In the re- search carried out in this work, the main motive for specialization is a higher level of knowledge in a very specific field. Therefore, it is justified to conclude that healthcare institutions should focus more on encouraging motivation among nurses, as this would improve the quality of healthcare services. If all the conditions of the workplaces were met, then the quality of the health service would not be left out (11).
Participants responded with the lowest rate of agreement to the statement “The process of training nurses is simple and easy”. It is known that the job of a nurse is extremely difficult and demanding, and also one of the most humane in the world. In order to be able to create a professional identity and provide adequate care to patients, it is necessary to receive continuous, i.e. lifelong, education. Education pro- grams should be adapted and accessible to everyone, and it is necessary to strive to create a supportive work environment that will enable to apply acquired knowledge and skills in practice.
The aim of the introduction of specialization is to train nurses to independently manage the processes applied in the health system, based on modern health protocols and guidelines. In this way, the previously described problem of lack of autonomy in the work of the nursing profession is successfully overcome. In the analysis of problems or obstacles when making decisions about specialization, the research results showed that nurses noticed certain difficulties in gaining autonomy due to limited powers and respon- sibilities in the existing organization of the health system. The introduction of specialization, however, can only be a step towards autonomy and the only way to change the perceived and real limitations of the current system in the long term.
Finally, it is important to mention certain concerns that have been raised in scientific and professional circles regarding the trend of specialization in nurs- ing. The concern mainly stems from the fear that a high degree of specialization will potentially threat- en the traditional holistic role of nurses in providing
health care to patients, that is, that the approach to nursing care will become significantly narrower and more fragmented (12). The results of the conducted research confirm that the participants themselves express certain concerns about the reduced possibil- ity of employee migration between different depart- ments. This fear, however, is not realistic because it is not realistic to expect that all available nursing personnel will decide to specialize.
The largest number of participants believe that spe- cialization in the nursing profession can lead to an in- crease in the quality of service, and the main reason for specialization is a higher level of knowledge in a very specific field of work. Also, the largest number of participants intend to continue their education, but most of them are not familiar with the possibili- ties of specialization within the profession.
Based on the hypothesis testing process, we con- clude that the attitude of nurses towards speciali- zation does not differ statistically significantly de- pending on the level of education, thus rejecting hypothesis H1. At the same time, no statistically sig- nificant connection between workplace and attitude towards specialization was proven, which is the basis for rejecting hypothesis H2.
In line with the trend of specialization in nursing, there has been scepticism and concern that a high degree of specialization will challenge the holistic role of nurses in patient care, narrowing and frag- menting the approach to nursing care. This thesis is not justified because not the entire available nursing staff is motivated to specialize.
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je namjeru nastavka obrazovanja te napretka na pro- fesionalnom planu. Ograničenje u toj namjeri proizla- zi iz činjenice da najveći broj ispitanika nije upoznat s programom specijalizacije iako svojim stavovima podržavaju specijalizaciju.
Odbačene su hipoteze kojima se testiralo razli- kuju li se stavovi medicinskih sestara/tehničara o specijalističkom obrazovanju s obzirom na radni staž, razinu obrazovanja i radno mjesto.
stručne spreme. U najvećoj mjeri zaposleni su na
bolničkom odjelu. Kao glavni motiv za specijalizaciju navode višu razina znanja u usko specijaliziranom području. Statistički značajno više ispitanika iskazalo
Ključne riječi: specijalizacija u sestrinstvu, stavovi medi- cinskih sestara/tehničara
