Factors Hindering Organizational Learning: Perspectives of Iranian Nurses

Background: Nurses can play a fundamental role in organizational learning being the largest group providing healthcare services; however, factors affecting their organizational learning are yet to be identified. Aims: To explore factors hindering organizational learning from the perspective of Iranian nurses. Study Qualitative content analysis on in depth semi-structured interview texts. Methodology: We recruited 16 nurses (5 men, 11 women; with a mean age of 36.4 years) working in clinical wards of hospitals affiliated to Kerman University of Medical Sciences. All interviews were transcribed verbatim immediately after they were conducted. Data were analyzed subsequently. Results: The data analysis from 16 nurses included in the study, revealed 5 main themes, including undirected training, role ambiguity, unfavorable work conditions, inadequate professional capabilities and feelings of subordination. Conclusion: Identifying factors hindering organizational learning from the perspective of nurses allows healthcare managers and policymakers to promote the quality of their nursing services and achieve patient and personnel satisfaction while facilitating organizational learning through designing need-based training courses for nurses, redefining nurses’ job description, revising nursing students' selection processes and trusting in nurses' capabilities.


INTRODUCTION
The wide range of changes made to the healthcare industry has led to a renaissance in nursing as a profession. These changes include a fundamental revision of structures in order to fulfill the growing expectations of healthcare institutes and to promote the quality of healthcare. Organizational learning is the key to discussions about how organization managers, especially nursing managers, can manage the situation more fittingly [1]. Organizational learning is an organization's ability to achieve knowledge, which involves the creation, acquisition and integration of knowledge for the purpose of modifying behaviors and promoting the organization's performance [2]. This concept is a latent, multi-dimensional construct involving different aspects of the management's commitment to learning, systemic views, spirit of openness and experimentation and the knowledge transfer and integration of [3]. In other words, it is a series of organizational practices, including the acquiring of knowledge, the distribution and interpretation of information and the conscious or unconscious memorizing of information, which entail positive effects for the organization [4]. Various studies conducted on the subject show that organizational learning affects job satisfaction, the ability to accept and deal with changes and challenges and organizational commitment in the personnel [5,6] and improves their professional competence [7]. Organizational learning is also essential for the survival, growth and competitive advantage of organizations [8]. Some studies have proved its contribution to innovation [9]. It also indirectly influences the intention to leaving job [5].
Experimentation, risk-taking, interaction with the external environment, dialogue and participative decision-making are five main factors that facilitate organizational learning [10]. In execution, organizational learning is sometimes faced with barriers and might eventually be discontinued. The barriers to organizational learning include the ambiguous feedback from the real world, interpretation differences, prevention from the flow of information within the organization and concealment [11], the management's failure to accept new concepts, a non-supportive organizational culture, heavy workloads, unfavorable environmental factors [12], the lack of clear measurable objectives, limiting job descriptions, unclear criteria for progress, high levels of stress and the lack of motivation in innovators [13].
Considering that today's organizations, including hospitals, have to work in a constantly-changing, unstable environment, there is a dire need for organizational learning to persist. The significant role of nurses as the largest group providing healthcare services in hospitals cannot be denied in the accomplishment of organizational learning and the promotion of healthcare quality. However, the study of factors hindering organizational learning is mostly limited to industrial settings and other work settings. Given the particular type of work interactions between nurses and the difference between clinical settings and industrial settings, the factors identified for other work settings cannot be extended to nurses and the study of these factors in clinical settings is crucial. Moreover, the few studies conducted on organizational learning in nurses have studied organizational learning capacities [14,15] or their relationship with the empowerment of nurses [16] and have not examined the barriers and determinants of organizational learning. Given the importance of the subject and the lack of qualitative and quantitative studies on it, conducting a qualitative study for gaining a deep and comprehensive understanding of factors hindering organizational learning in nurses appears essential. The present study was conducted to explore factors hindering organizational learning in clinical nursing.

MATERIALS AND METHODS
The present qualitative study was conducted using the conventional content analysis method. Descriptive qualitative studies are common in the field of nursing and aim to gain a deep understanding of phenomena [17]. Content analysis is a widely-used technique in qualitative research that interprets the meanings of textual data. Conventional content analysis is the direct extraction of codes and categories from textual data. This technique is often used when there are few theories or studies on the research subject [18]. Given the study subject and the limited number of similar studies conducted on it, conventional content analysis was used in the present study to ensure that the data are indeed the result of the interviews conducted with participants. The present study is part of a broader grounded theory study.

Data Collection
Participants were selected through purposive sampling with maximum variation, which is a sampling method often used in qualitative studies for its advantages and its ability to properly clarify the phenomenon in question and identify the main patterns involved in that variation [17]. A total of 16 nurses working in clinical wards of three hospitals affiliated to Kerman University of Medical Sciences who met the study inclusion criteria were therefore interviewed. The inclusion criteria consisted of having a bachelor's degree or higher in nursing, having at least one year of clinical work experience, being currently employed in clinical wards, being physically, mentally and cognitively healthy, and being able to communicate and share experiences. For obtaining accurate data and gaining a deep understanding of the different dimensions of the phenomenon in question, participants were selected from both male and female genders, with different job positions and levels of education, different age groups and different work experiences.
Data were collected using in depth semistructured interviews aiming to extract complicated answers containing a large amount of information. The researcher thus perceives how participants think and feel, what experiences they have, and how they perceive the world. The interview began with general and personal questions as well as open-ended ones on the objectives of the study. For example, "Can you talk about your learning experiences in the organization? What barriers did you face?". The interview then continued with exploratory questions aiming to clarify the concept and get more in-depth information. For example, "What happened in those instances? What did you do?". Further questions were asked according to the emerging data and the interview progression. Data collection continued until data saturation; that is, until all the concepts under study were clearly defined and further interviews did not generate new categories. After the objectives of the study were briefly explained to participants, the place and time of each interview was determined according to participants' preferences and in a way that allowed maximum concentration for both parties so that their thoughts would not be disturbed by intervening factors. Interviews lasted 45-100 minutes (with a mean duration of 65 minutes) and were recorded using a digital recorder.

Data analysis
Data were collected using 16 in-depth, semistructured interviews that were then analyzed through conventional content analysis. The researcher went over the interviews several times immediately after they were conducted and then transcribed them verbatim. The analysis began with frequent readings of the entire text for a better immersion in the data and to get a general idea of them. With the cooperation and agreement of the research team, the codes were arranged and classified in primary categories according to their similarities and differences. Subcategories were formed with similar events and outcomes and the main categories were then set. This subjective procedure continued until the themes were extracted. MAXQDA-10 was used to facilitate the data analysis, categorization, constant comparisons and quotation retrieval.

Data Trustworthiness
The validity of the data was determined using Lincoln and Guba's evaluative criteria [19]. Longterm cooperation, the researcher's extensive contact with the data, favorable communication with participants, maximum variation in sampling, the integration of data collection methods (observations and field notes), peer-reviews by collaborators and participants, revision of the coding and categorizations by the research team, writing field notes and memos were among the criteria used for the assessment of the validity of the data.

RESULTS AND DISCUSSION
The present study was conducted on 16 nurses with a mean age of 36.4 years and a mean work experience of 13 years. Participants included 11 female and 5 male nurses with different educational backgrounds; 10 nurses had bachelor's degrees in nursing, 4 had master's degrees and 2 were PhD students in nursing. The interviews were held at participants' workplace (14 cases), the researcher's workplace (2 cases) or participants' homes (2 cases); Table1.
The results obtained reflect only the factors hindering organizational learning; facilitating factors have therefore not been discussed in the statement of the results. The analysis of the data revealed 5 main categories, including undirected training, role ambiguity, unfavorable work conditions, inadequate professional capabilities and feeling of subordination; Table 2. It should be noted that these results have been reported in line with the objective of the study; that is, defining factors hindering organizational learning.

Undirected Training
Participants found formal training courses, such as continuing education courses and conferences held within the wards to be undirected and inefficient. This main theme consisted of a number of subthemes, including mandatory continuing education courses, inadequate needs assessment, disregarding the interests of the personnel, inappropriate execution and the lack of proper evaluation systems.

Mandatory continuing education courses
The promotion and evaluation of all nursing personnel depends on their attending of special continuing education courses and presenting their certificates. The results of this study showed that the mandatory nature of these courses distanced nurses from the main objective of the courses. For instance, a training supervisor with 19 years of work experience believed: "I actually feel the instructions we give in the weekly sessions in our ward or at the patients' bedside, or the continuing education courses that we provide are useless. Many of our colleagues attend these continuing education courses only for their certificates, only because they have to have fulfilled hours of training requirement for their evaluations".

Inadequate needs assessment
The disregard for nurses' training needs and the inadequate needs assessments performed were factors reducing the nurses' motivation for active attendance of the training courses. A male nurse with a bachelor's degree and 8 years of work experience in the neurology ward stated: "They give us a form and ask what our needs are, but everything's just on paper. They've given us these forms 20 times now, and we've written down our needs. For example, X should teach us CPR or we would talk about the most common diseases of the ward in our monthly sessions. But their only concern seems to be accreditation".

Disregarding the interests of the personnel
Taking account of the interests of the personnel in determining the subject of the monthly conferences is an effective factor in motivating participants and promoting the efficiency of the instructions. However, nurses were obliged to present on a subject based on the list provided annually by the matron at the beginning of each year. One male nurse working in the surgical ward said: "See, you can't even choose the subject yourself. You want to present on a subject you're interested in or that you can discuss well. But no, they give you a subject and ask you to prepare your presentation on it. This is merely an obligation. They don't even give us any feedbacks, not as the presenter and not as anything else. It's only about the meeting minutes".

Inappropriate execution
According to the nurses, one of the causes of the inefficiency of training was its inappropriate execution and bad time schedules; they also believed that holding continuing education courses with bad time schedules took their motivation for learning. One participant elaborated on this issue: "These classes aren't useful at all. Classes should be short and at the patients' bedside. For example, the training supervisor of each shift can come in and give a certain instruction and then come back later to see if they have complied with it; it's of no benefit sitting in class after three or four hours on a night shift. Of course you won't learn anything then".

The lack of proper evaluation systems
The lack of proper evaluation systems and a mere emphasis on physical presence have resulted in a general disregard for the quality and future practicality of the training courses at the patients' beside.
"It's not important at all for the system if the nurse working with a patient has really learnt from the courses and practices her learnt skills or not. Evaluations are perfunctory. There's never been even one nurse who has attended the continuing education courses but not received the certificate".

Role Ambiguity
The analysis of the results showed that nurses are agonized by the disorganized enforcement of the nursing job descriptions and the interference of responsibilities. Overall, this ambiguity is considered a barrier for nurses against making efforts to acquire more knowledge and taking a step toward organizational learning. Confusion and the contradictory duties and job descriptions were the two subthemes of this main theme.

Confusion
The job description devised for nurses was problematic in practice, and the resultant confusion comprised a major part of participants' experiences. One nurse working in the gastroenterology ward explained: "… Our responsibilities aren't clear. They're clear on paper but not in practice. I think nursing doesn't have a clear job description at all, in our ward for instance, and we still don't know if we should insert the NG, or if an intern should or a nursing attendant".

Contradictory duties and job descriptions
The contradictions included the imposition of duties not mentioned in the job description and without providing the required support, prevention from pursuing the legal duties and admonishment for issues irrelevant to the job description.

The imposition of duties not mentioned in the job description
At times, medical students and assistants informally ask nurses to perform tasks that are out of the nursing job description. One participant gave an example: "An example of the contradictions is that an intern who doesn't know anything is allowed to perform an arterial blood gases test and he may fail, so he then asks a nurse to draw a blood sample! The nurse comes in and does it although it's illegal. And if anything goes wrong, they blame it on the nurse and ask her why she has done it".

Prevention from pursuing the legal job description
Nurses are prevented from pursuing some of their legal duties by the internal rules of hospitals. For instance, if an intern is present in the ward, nurses are not allowed to perform dressings or pull out the drain.
"… The nurses here are educated, have the required knowledge, they have constantly practiced it with accuracy, but they aren't allowed to perform dressings or remove stitches in the ward. I mean, they aren't allowed to perform the exact task they've been trained for!".

Admonishment for issues irrelevant to the job description
In addition to the discussed issues, the admonishment of nurses for issues that were not directly related to patient care was another problem. In the experience of one nurse working in the intensive care unit: "Sometimes we were only two personnel with 22 patients in the surgical ward. The supervisor would come and complain why this or that lamp was burnt out, or why the flush wasn't working in three of the bathroom stalls. She wrote reprimand letters for us. Am I responsible for checking how many lamps are burnt out or why the door isn't working? For any problem that might occur, a nurse is always the first to be admonished".

Unfavorable Work Conditions
Describing their work conditions, the nurses mentioned factors that were hindering their learning. The subthemes of this theme included the lack of time, heavy workloads, not feeling the need for learning and being deprived of the motivation for learning.

The lack of time
Analysis of the transcribed interviews showed that nurses did not have enough time to study, carry out research and generally promote their capacities, due to their financial concerns. One participant said on this issue: "Nurses feel the need to learn, but they don't have time. They will be in deep trouble if they want to live on just one salary someday. They usually work in 2-3 departments to make a living. Do you think a nurse who goes to EMS 115 after her night shifts and then back to the hospital has any time for learning? She is only trying to make a living to actually get somewhere".

Heavy workloads
In addition to its physical and mental health risks, nurses' heavy workloads made them forget to even try to promote their capacities and the organization and to accomplish organizational learning. One nurse stated: "If you want to learn something here, well, we don't have the time. Our nurses have neither the time for carrying out research nor for using the library. They don't have the time to study. They're always working. Some nights, they have 30 patients and only three personnel on site. Worst of all is the writing part of their tasks. Checking vital signs doesn't take even two minutes, but then you have to spend 5 minutes to record it on three or four papers."

Not feeling the need for learning
The nurses said that they did not feel the need for learning when simply performing routine nursing tasks. One nurse with a bachelor's degree who was working in the CCU said: "… Nurses know that, no matter how good they actually are or aren't, can still insert IV lines, adjust its dose and administer a bunch of drugs to the patients, because we've been working for twenty years and nothing bad has ever happened. After working for some time in this system, you learn not to learn. Because you realize nothing bad happens when you do things the way you do. When I see I'm at more ease like this, I finish my shifts without bothering myself at all".

Deprivation of the motivation for learning
The failure to get the right job position and the system's indifference took away the motivation of the personnel who were in any way trying to promote their capacities and thereby improve the quality of care.

Failure to get the right job position
Continuing education does not guarantee a better job position for nurses or even any significant changes in their financial status. A training supervisor believed: "We see now that even nurses with master's degrees or PhDs don't have a suitable position. The same old routine tasks make them disappear in the system. No changes are madeeven financially."

The system's indifference
In this system, managers' indifference toward the personnel's efforts for organizational learning directs them toward a mundane existence.
"… no, the system doesn't motivate us. There's no difference between the personnel with more knowledge and the ones without. This is the whole truth. There's no encouragement and no promotion. And so we've gotten used to this mundane."

Inadequate Professional Capabilities
The selection of nursing students through national university entrance tests and the lack of necessary filters for the assessment of the skills required for entrance have resulted in the admission of individuals who do not meet the primary qualities for entering the field of nursing. The presence of informed and enthusiastic individuals with a clear perception of organizational objectives is necessary for the implementation of organizational learning.

Uninformed selection
Entering the field of nursing uninformed and without any interest has made some personnel seek a way to escape the job rather than try to understand its organizational objectives and accomplish organizational learning.
"Nursing [pauses], I didn't know anything about it at all. I mean, I entered the field by chance. I started regretting my decision from the first day entering the field until now. Now I'm thinking about finding a way to escape this job. The only thing I don't think about is learning; unless I feel it harms the patient".

Uncertain entrance
Moreover, the nurses believed that they had not acquired the fundamental capabilities necessary for dealing with real work settings.
"… I actually had very little information when I began working. I, myself, felt I had very little information. Although I was the top student at school, there were many tasks I didn't know how to perform when I entered the ward".
A training supervisor proposed the inconsistency between the training provided in nursing schools and that provided in hospitals as one cause for the nurses' feelings of incapability: "For example, one patient had stomach bleeding in the ward and needed an N.G.Tube. They hadn't inserted any for him. I asked why they hadn't inserted it. The nurse answered, 'when I have never inserted a catheter once during my 4 years of school, how can I do it now?' She was right".

Feelings of Subordination
Most nurses expressed feelings of subordination caused by the system's distrust in their scientific capabilities and skills and the unpleasant view of the society toward nursing. The effect of this feeling was so strong that it ruined the nurses' motivation for innovation and the proposal of new ideas in the organization and made them frustrated with the improvement of the conditions and stopped them from pursuing organizational learning in the initial stages.

Distrust in the scientific capabilities and skills of nurses
The lack of independence in nursing and in the use of learned skills induced a feeling of distrust in the nurses.

The lack of independence in nursing
The nurses were dissatisfied with their level of independence in performing healthcare duties and believed that their powers were very limited compared to their capabilities. One participant said: "… Imagine a patient is admitted to the ICU, and you diagnose him with an increased ICP. You can't do anything for the patient at the initial stage; you don't have the power to do anything then. We should only report it, although we can decrease the patient's ICP with only a slight change in the device settings".

The lack of independence in the use of learned skills
The lack of independence in the use of learned skills and the dominance of the physicians' ideas were concerns frequently expressed by the nurses. An ICU matron with twenty years of work experience said of the lack of independence in the use of learned skills: "Nurses can't do what they've learned to do. Unfortunately, the system doesn't allow nurses to use their knowledge. When you want to implement a nursing protocol and do something scientific, the system may resist or the physician may easily disagree. There's no way they would ever just agree with you".

The unpleasant view toward nursing
Another dimension of this distrust was rooted in the society's view of nursing. The unfavorable social prestige of nursing has imposed an atmosphere of indifference and weakened motivation for organizational learning and job promotion. One of the participants believed that even the best nurses with the highest academic degrees and professional skills cannot acquire a suitable position for themselves in the healthcare system and in the society.
"The ones who can find work just leave. And the better nurses who've stayed, when you're talking to them, 100% of them are dissatisfied. For example, the matron … she is really the master in the emergency ward, but she says that you amount to nothing in this field even if you're the best, and the society thinks nothing of you. Because you are not seen at all. Under the circumstances, can we expect nurses to seek learning?".

Discussions
Organizational learning plays an essential role in the promotion of the quality of healthcare, devotion to work, nurses' job satisfaction, and the overall survival of the organization. The results of the study provide a new perspective on factors hindering organizational learning in nurses. The experiences of the majority of the nurses revealed the dominance of hindering factors and a frustration with the accomplishment of organizational learning in the circumstances governing the hospitals.
Unlike the common expectation about the positive role of continuing education courses in improving the quality of healthcare, the study participants proposed formal training, such as continuing education courses and conferences held within the ward, to be undirected and inefficient due to their compulsory nature, the lack of proper systems of evaluation and the disregard for nurses' needs. Participation in these courses takes place solely for the purpose of receiving a certificate and an annual promotion. These results were consistent with the results of a similar study conducted in Iran [20]. The consistency of continuing education courses with the personal professional objectives of nurses and the evaluation of nurses at the end of the courses and continuing to follow up their progress and compliance are strategies for the success of these programs [21]; therefore, managers and planners should take account of these factors in their attempts to facilitate organizational learning through training courses.
In the present study, the nurses said that they had to bear a certain ambiguity in the roles assigned to them and expressed their dissatisfaction with the system's failure to adhere to the established job descriptions and its imposing of irrelevant tasks on them. This issue was also mentioned in a similar study conducted on Iranian nurses [20]. Ambiguity in roles acts as a barrier to organizational learning [13,22]. Managers of the system can raise the nurses' motivation for the acquisition of knowledge and skills and personal and organizational improvement through measures such as controlling the nurses' precise adherence to the job description, defining the limits of their responsibility and supplying the required workforce.
The experiences of nurses participating in this study revealed factors interfering with their process of learning. The nurses' lack of time and not feeling the need for learning and deprivation by the system of the motivation for learning made them unwilling to take a step toward personal and organizational learning, and the heavy workloads and financial concerns did not give the nurses ample time for studying and carrying out research and generally promoting their capacities. These factors are considered barriers against organizational learning (Lin, 2008). Other studies conducted in Iran also yielded similar themes [20,23]. Nursing managers should leave ample time to nurses to study and carry out research through employing sufficient workforce and improving the nurses' financial conditions. Moreover, they should evaluate the nurses' clinical competence frequently through granting them a work license and holding periodical exams so as to prevent feelings of mundaneness and the non-importance of learning in them. Appreciating the nurses' efforts for personal and organizational improvement and encouraging them through various ways can increase their motivation for organizational learning.
The nurses participating in this study described their entry into the field of nursing as an uninformed decision without any enthusiasm and also believed that they had not acquired the capabilities required for dealing with real work conditions due to the inconsistency between the system's theoretical trainings and the clinical needs of the society and the impertinence of their training. Other studies also revealed Iranian nurses' negative perception of their own possession of the characteristics required for working in this profession [24]. The feelings of uncertainty and the distrust in one's own knowledge were a barrier to their transmission of information and the use of their learned skills [20]. Due to the sensitive nature of nursing as a profession, healthcare policymakers need to take account of knowledge and interest in the selection of nursing students in addition to the score obtained in the entrance exam and to thus prevent the entrance of uninformed and unenthusiastic individuals into nursing and its subsequent negative outcomes. Creating a nursing training that is consistent with clinical needs guarantees the nurses' acquisition of the capabilities required for entering this profession. Feelings of subordination expressed by the majority of the nurses had a significant role in weakening their motivation for innovation and proposing new ideas and consequently made them indifferent to the conditions. Organizational learning, however, is the result of sharing viewpoints and suggestions and using the experiences of others for further promotion of the organization [3]. The results of a study conducted on Iranian nurses revealed that nursing personnel tend not to be assertive in the communication of their views and making suggestions [15].
In the present study, nurses complained about the system's distrust in their scientific and professional capabilities, which was manifested in their lack of independence. Similar studies conducted on the topic also reveal feelings of subordination and a lack of support and the little contribution to decision-making [11,20,25,26] and smaller professional independence in nurses [27]. The nurses participating in the present study considered their profession lacking in social prestige and believed that they could not find their right position in the system and in the society even with the highest academic degrees and professional competence [23]. This image has mainly been created by the nurses themselves due to their inability to debate and their invisibility in the society [28,29]. The nurses' feeling of subordination is a warning for the managers of the healthcare system. Modifying the current conditions and eliminating the adverse effects of nurses' indifference toward the organization's conditions and its inhibiting role in organizational learning calls for improving the nurses' professional independence and modifying the social prestige of nursing in the society. The healthcare system can also benefit from the experiences of other countries that have successfully granted more independence to their nurses, including the right for writing prescriptions, the establishment of nursing clinics using decision-making support systems, acquainting the members of healthcare teams and the society with the capabilities of nurses and promoting participative decision-making.

CONCLUSION
With such points of strength as the physical presence of the researcher in the study setting and her deep communication with participants, the present study demonstrated factors hindering organizational learning in nurses from different perspectives. The results of this study stress the importance of participative decision-making and higher independence in nurses. Identifying the factors hindering organizational learning from the nurses' perspective allows managers and policymakers of the healthcare system to facilitate the entry of motivated and enthusiastic nurses to clinical settings and to improve the quality of nursing care services and bring satisfaction to the patients and the personnel in addition to also encouraging organizational learning through trusting the nurses' capabilities, planning for need-based training courses for the nurses, adhering to the nurses' established job description and revising nursing students' selection processes.

LIMITATIONS
Although generalization of the data is always pursued with caution in qualitative research, and although this study is not an exception, the researchers tried to describe the phenomenon in question with as much richness as possible through the purposive selection of participants and the satisfactory setting of the time and place of the interviews. Participants were not concerned about their job duties during the interviews and the researchers postponed the interviews whenever participants felt tired and stressed. No problems therefore occurred during the study and none of the participants withdrew from the study.

ETHICAL APPROVAL
Before beginning the data collection, the study was approved by the Research Council of the School of Nursing and the Ethics Committee of Kerman University of Medical Sciences under the ethical compliance code of K/93/154 and the approval code of 93/305. The researcher visited the study setting in order to gain familiarity with the eligible nurses, to introduce herself and explain the research objectives and to then invite the nurses to participate in the study. The nurses submitted their informed written consent for participation in the study and for having their interviews recorded. They were then ensured of the confidentiality of their information (their names and any other identification clues were removed from both the recorded interviews and the transcriptions) and told that they could withdraw from the study whenever they wanted. Ethical considerations were respected during all the processes of the study, from recording and transcribing the interviews to publishing the results.