Development of Filipino Nurse Educator’s Wellbeing Survey (FNEWS): An Exploratory Sequential Mixed Methods Study
Jordan T. Salvador1, *, Friyal M. Alqahtani1, Rima S. Sareh Al-Garni2
Identifiers and Pagination:Year: 2019
First Page: 139
Last Page: 152
Publisher Id: TONURSJ-13-139
Article History:Received Date: 08/04/2019
Revision Received Date: 22/07/2019
Acceptance Date: 31/07/2019
Electronic publication date: 31/08/2019
Collection year: 2019
open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
The role of a nurse educator is a vital component in the management process of teaching and learning development of students. Ensuring excellent wellbeing for nurse educators may lead to increased job satisfaction and work performance.
The objective of this study was to develop a survey tool that measures the wellbeing of Filipino nurse educators working in four Gulf Cooperation Council (GCC) countries.
Three-phase sequential approach was obtained. The investigation started with a qualitative investigation of 20 Filipino nurse educators based from Saudi Arabia, United Arab Emirates, Oman, and Bahrain followed by a development of survey tool measuring the Filipino nurse educator’s wellbeing. The survey tool was distributed among 112 participants in Saudi Arabia. Data were analyzed and interpreted by means of a Colaizzi method for qualitative and descriptive statistics using SPSS for quantitative measures.
All the themes emerged from the qualitative phase were discussed from the gathered review of literature and studies. Themes, contextual categories, and significant statements were used as survey constructs measuring the wellbeing of the participants. Moreover, a valid and reliable survey tool called ‘Filipino Nurse Educator’s Wellbeing Survey’ (FNEWS) was developed and surveyed among the Filipino nurse educators in Saudi Arabia, revealing an ‘acceptable’ level of wellbeing.
Knowing the level of wellbeing of nurse educators will be an effective way to provide the competency needed to address burnout, low job satisfaction, and compassion fatigue, thereby increasing the likelihood of safeguarding the welfare of the nurse educators.
Nursing education in the Gulf Cooperation Council (GCC) region, a part of the Middle East, is quickly growing when it comes to the number of students desiring to become a nurse . The role of a nurse educator is essential to this phenomenon especially in the learning process of qualified nurses with adequate knowledge, skills, and attitude to take care of the public health . Majority of nurse educators in the region, especially in Saudi Arabia and Oman, were from the Philippines, Sudan, Jordan, Egypt, and India with excellent academic qualifications and clinical expertise . This is why numerous and quick hiring job placements had been publicized for nurse educators in various social media platforms. In fact, GCC countries were offering good benefits and salaries to Filipino nurse educators looking for great opportunities and who were tired of low salaries and uncompensated workloads. They believed that the only way to improve their wellbeing was to accept this once in a lifetime offer .
Schimmack  defined ‘wellbeing’ as a preference realization, which can be measured by both cognitive and affective measures. Various literature stated that wellbeing is also believed to embrace human satisfaction in terms of physiological and health, employment stability, education, financial capacity, socio-cultural and religious practices, customs and traditions, family and significant others, and the environment [6-8]. This is why Naci and Ioannidis  came up with the idea that ‘wellbeing’ was an interconnecting dimension of mental, physical, and social aspects of human beings. Reflecting on this issue, the researchers came up with the question, ‘would the Filipino nurse educators achieve their optimum wellbeing if they decided to live and work in the GCC region’
There were quite a few published articles pertaining to the wellbeing of a nurse educator; however, no literature tackled the wellbeing of Filipino nurse educators in the GCC region. To get an idea or a comparison on how nurse educators attain their wellbeing, a review of related literature from both international and local studies were sought to better understand the phenomenon that will be investigated. One significant study about the wellbeing of a nurse educator was Owen’s convergent parallel mixed-method design . Owen’s project examined the relationship between life experiences, wellbeing, quality of life, and life balance of nurse educators. The study found out that poor nurse education balance can lead to nurse educator’s dissatisfaction, compassion fatigue, and burnout. Owen’s themes generated from the accounts of the participants were support, demands, workloads, and personal/time attributes . Since there was no available literature about the wellbeing of Filipino nurse educators in the GCC region, this study would be a great contribution to the growing body of knowledge about nursing education.
To better understand the experiences of the Filipino nurse educators and determine their level of wellbeing, an exploratory sequential mixed methods study was done to develop a survey tool that would measure the wellbeing of Filipino nurse educators working in the GCC region. Hence, it would enlighten all nurse educators and researchers pursuing deeper understanding behind a successful groundwork in preparing for international employments. Furthermore, the study focused and answered the following research questions: (1) How did Filipino nurse educators fulfill their wellbeing in the GCC region; (2) What self-developed tool can be formulated based on the qualitative investigation; and (3) What was the level of wellbeing of the Filipino nurse educators working in Saudi Arabia.
2. MATERIALS AND METHODS
2.1. Research Design
This study utilized exploratory sequential mixed methods design that utilized both qualitative and quantitative methods. Creswell  characterized this type of design with two phases, which was initiated by a qualitative data gathering and analysis followed by a quantitative process with the determination to generalize the level of wellbeing of Filipino nurse educators in a specific GCC country. The researchers had chosen this design because it could utilize the quantitative findings in analyzing and interpreting the results of the qualitative investigation. Moreover, the researchers believed that it will be useful in testing a newly developed quantitative tool and helped them to identify significant variables for quantitative studies especially when the variables are unspecified . Creswell and Plano-Clark  stated about exploratory mixed methods design that it will be beneficial when, “measures or instruments are not available, the variables are unknown, or there is no guiding framework or theory” (p. 75). Another reason why the researchers ended up choosing this research design was that it specifies a deeper understanding of the experiences of Filipino nurse educators. Lastly, this would lead to discovering new insights that would uncover the essence of the phenomenon under investigation and eventually measure its prevalence [11-13].
This exploratory sequential mixed methods study was in three phases. The first phase initiated a phenomenological-based approach. It was chosen for this study because the researchers believed that it was the best way to understand the meaning of an individual’s lived experiences towards a certain phenomenon  and in order for a researcher to come up with suitable constructs, the researchers must investigate thoroughly the phenomenon . One advantage of this study was it offered validity . In phase 2, all qualitative themes and contextual categories were used as constructs in developing a survey tool for Filipino nurse educators in the GCC region. The survey tool was evaluated by a panel of experts in the field of nursing for validity and reliability . Lastly, for phase 3 and the final phase, a descriptive cross-sectional survey was done to figure out the level of wellbeing of the Filipino nurse educators working in Saudi Arabia. Thus, this empirical process provided a quantifiable and measurable outcome.
2.2. Participant Selection
Phase 1 of the study was conducted in selected GCC countries (n=4): Bahrain, Oman, Saudi Arabia, and the United Arab Emirates excluding Qatar and Kuwait since there were few to none nursing institutions in these countries. The participants (n=20) were from: Saudi Arabia (n=6), Oman (n=6), UAE (n=4), and Bahrain (4). For the purpose of homogeneity, inclusion criteria were as follows: (1) A Filipino nurse educator working in government or private nursing college and university in the GCC region; (2) A minimum of 4 years teaching experience regardless of gender, age, religion, and socio-cultural specifications; and (3) Willingness to consent and contribute to the investigation. In selecting the participants, the researchers utilized a purposive sampling method and snowballing technique in gathering the participants for the semi-structured interview. Furthermore, Filipino nurse educators were chosen because they were currently one of the foreign nationalities with the most number of educators in the GCC region. The total number was based upon the data saturation level of the participants’ rich description of the phenomenon under investigation.
For the quantitative phase, participants (n=112) were surveyed through simple random sampling. None of the participants in the first phase joined the third phase . Moreover, the researchers considered only Saudi Arabia amongst other GCC countries since it had the greatest number of Filipino nurse educators in the GCC region.
2.3. Research Team
The research team comprised of one male and two female assistant professors at Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. All researchers (JS, FA, and RA) had experiences in conducting both qualitative and quantitative studies. One researcher (JS) had experience in conducting reviews for both research designs. To ensure that research processes and methods were correctly done, researchers attended several workshops and tutorials to ensure that reporting is accurate and complete.
2.4. Philosophical Underpinning
It is imperative to know the philosophical underpinnings of the study as stressed by Creswell and Plano Clark  in order to give a concise overview of the research design used. Patterson  mentioned that it is the philosophical foundation that induces mixing of the quantitative and qualitative models into single research. This study had philosophical assumptions too that guided both approaches especially in the data collection and analysis . The pragmatic perspectives of this study used both deductive and inductive logic reasoning in revealing the meaning of the phenomenon. For an instance, an individual mind is incapable of the objectivity that is necessary to uncover the reality existing in the objective reality, so this design will value not only the essence of the objective but the subjective point-of-views as well. More so, combining both approaches in this study will provide a better interpretation of the phenomenon. This paradigm war did not end until pragmatists suggested that instead of delving into the irreconcilability, mitigating the gaps, and the connections between the two paradigms were recommended . Therefore, the pragmatic philosophical groundwork of this study provided an organized implementation of the suitable qualitative and quantitative methods in achieving the aim of this study [18, 19].
2.5. Ethical Considerations
The researchers sought the Ethics Review Clearance from SPUM Institutional Ethics Review Committee (SPUM-IERC). An application was sent with all the pertinent documents needed to grant clearance. The ethics review clearance was given on 06 November 2017. Moreover, the researchers also obtained a National Institutes of Health (NIH) certification regarding protecting human research participants to ensure that ethical considerations would be implemented and followed all throughout the study.
2.6. Data Collection
Data were collected from 06 November 2017 to 06 May 2018. Upon identification of the participants and securing of written informed consents for phase 1, the researchers explained the aim and essential details of the study that were needed to be disclosed to show transparency. Methods of collecting data included the use of audio-recording equipment, field notes (personal, transcript, and analytical), and some qualitative documents shown by the participants (optional). In addition, the researchers utilized a semi-structured interview guide consisting of open-ended questions as given in Table 1 [11-13]. This allowed the researchers to ask follow-up questions in order to clarify the participants’ rich narrative descriptions. Probing questions allowed the researchers to have a deeper understanding of the facts presented by the participants . Before conducting the actual interview, three participants were asked to join a pilot study to establish construct validity, which would help the researchers to discover questions that were not clear, were misleading, and/or were inappropriate [20, 21]. The researchers scheduled the date, time, and place of the interview conforming to the available schedules of the participants. Most of the interviews were conducted during the participant’s day-offs. All face-to-face interviews lasted for 30 minutes to 1 hour. Participants were given pseudonym initials (e.g. Simple Rhythm = SR) for privacy and confidentiality. Lastly, all participants were given the autonomy to refuse answering the interview question and they were given the chance to withdraw at any point of the investigation if they felt uncomfortable.
All the themes emerged from the qualitative finding were used as constructs in developing the survey tool that would measure the wellbeing of Filipino Nurse Educators in the GCC region, which will be explained extensively in the data analysis section. After the creation of the survey tool, the researchers immediately conducted a cross-sectional survey using an online platform, Google Docs, in gathering the data.
|• Can you tell me how was it like to be a nurse educator in a foreign country particularly in the GCC region?
• What are your feelings regarding your experience/s?
• In your personal view, what is the meaning of your experience?
• What are the challenges or difficulties you have had living and working in a foreign country?
• How do these challenges, good or bad, impact your personal and professional development?
• How do you handle stress in your personal life, work, and relationship with others? Who are your support persons?
|• What are the usual activities you engage aside from the customary undertakings of a nurse educator? How do you spend your usual day?
• How do these activities contribute to your life personally and professionally?
• How do you view life in totality as a nurse educator living and working in a foreign country?
• How do you see yourself in the future? Can you share your future plans?
• Can you tell me the meaning of your whole experience living and working in the Middle East?
2.8. Data Analysis
The role of the researcher was the key element in the qualitative investigation through which the data were gathered and analyzed. Patton  reasoned, “credibility of qualitative methods, therefore hinges to a great extent on the skill, competence, and rigor of the person doing the fieldwork” (p. 14). In analyzing the data, the researchers’ biases were bracketed to focus on the inductive process rather than the deductive approach [23, 24]. Data were collected and analyzed through Colaizzi method . After completing the seven data analysis steps of Colaizzi, the researchers sent back the transcriptions and results of the analysis to the participants for comments and clarifications. This gave the participants the chance to explain their original words and texts, expounded what they want to convey, modified misunderstood experiences, added more information, and edited grammatical errors and typos [11-13]. Consolidated Criteria for Reporting Qualitative (COREQ) was utilized to authenticate the final reporting of the results .
3.1. Qualitative Phase
Themes were defined as patterns across the data sets, which consist of contextual categories . Contextual categories were the results of the deductive formulated meanings of the participants’ significant statements that were organized in the same thematic constructs. In qualitative studies, the themes can independently answer the grand tour question. For instance, the emergent themes of this study can answer the first research question, how did Filipino nurse educators fulfill their wellbeing in the GCC region? As a result, five themes and seventeen contextual categories had emerged as findings of the qualitative investigations given in Table 2. The emergent themes were also explained in the succeeding paragraphs according to its conceptual descriptions followed by some examples of significant statements found in Table 3.
3.1.1. Nurturing Physical and Physiological Dimension
This dimension embodied how Filipino nurse educators nurtured their physical and physiological wellbeing. This dimension is a vital component of an individual’s wellbeing. Ideal physical and physiological wellness can be actualized through an excellent combination of activities of daily living (self-care activities) and instrumental activities of daily living (not necessary for fundamental functioning). Likewise, it embraced how Filipino nurse educators adapt to a different diet and how they managed stress, anxiety, and diseases. Based on the participants’ accounts, creative diversional activities, enough rest and sleep were essential in sustaining optimum wellbeing. Moreover, knowing and understanding physical and physiological dimension provided an individual the motivation to be aware and conscious about health their status such as monitoring vital signs (e.g. blood pressure, heart/pulse rate, respiratory rate, and temperature) and eventually recognize the warning signs and symptoms of a disease. Nurturing the physical and physiological dimension would let an individual appreciate and realize the correlation of a healthy and stress-free lifestyle. Lastly, this dimension can be achieved by motivating oneself to engage with proper activities of daily living (e.g. exercise, walking, etc.), balanced diet, and health monitoring.
3.1.2. Enhancing Learning Dimension
This dimension had relevance on how Filipino nurse educators enhanced their learning capacity in terms of: (a) managing communication and language barriers (verbal and non-verbal cues); (b) existential perceptions (insights, point-of-views, and reflections); (c) living up the core values (open-mindedness, active listening, humor, respect, positivity, self-contentment, dedication, hard work, commitment, passion, acceptance, self-discipline, independent, positivity, professionalism, trust, flexibility, patience, caring, creativity, and resourcefulness); (d) application of coping mechanisms (constructive, destructive, adaptive, and maladaptive); and (e) acquisition of new competencies (time management, skill development, critical thinking, resilience, patience, perseverance, and calmness). This dimension captured how the participants used these experiences in their daily lives and continuously developed their cognitive (knowledge), affective (attitude), and psychomotor (skills) learning domains for future endeavors.
|Contextual Categories||Emergent Theme|
|Activities of Daily Living (ADL) and Sustained Instrumental Activities of Daily Living (IADL)||
Nurturing Physical and
|Adapting to a Different Diet|
|Managing Stress and Diseases through Diversional Activities, Rest, and Sleep|
|Managing Communication Barriers||
|Living up the Core Values|
|Application of Coping Mechanisms|
|Acquisition of Competencies|
|Improved Socio-Economic Stability|
|Engaging in Religious Practices||
Enriching Religious and
|Adjusting to a New Legal Environment|
|High Sense of Professional Competence||
Expanding Professional and Occupational
|Adjusting to Transcultural Relations in the Workplace|
|Personal and Professional Development|
3.1.3. Strengthening Social Dimension
This wellbeing dimension depicted the strengthening of the various social dynamics of the Filipino nurse educators that included: (a) interpersonal relationship (how individuals build friendship, homesickness, intimacy, support system, and serious relationship, thus, it figures out the sense of belongingness of an individual); (b) socio-cultural factors (cultural differences, culture shock, isolation, and acculturation); (c) environmental safety (climate change, geographical location, and security and protection); and (d) socio-economic stability (financial capacity).
|Contextual Categories||Significant Statements|
Activities of Daily Living
Activities of Daily Living (ADL)
“My usual days would be assisting the Dean and the Vice Dean for Quality Development, Lectures and meetings with the College Unit Groups, attend workshops/lecture sessions on Faculty Development and Nursing Department I belong to.” (KF, Interview 10, Line 15).
“I usually go out for a coffee with my friends twice or thrice a week and during weekend, I go to Zulfi, 1.5 hours away from my place to visit my close friends. Mostly, I spend my day driving after work to go home, rest for a while, cook dinner, then go out a coffee or sometimes, I get my friends from their house, try to go to supermarket for groceries, went back home and cook dinner with them.” (NB, Interview 20, Line 48-49).
Adapting to a
“In general, the attitude and behavior of other countries. The food that I eat here is more oily, salty and fatty, which makes me now hypertensive resulting me to have maintenance for 5 years already.” (SR, Interview 8, Line 11).
“When I first arrived in Saudi Arabia these are challenges or difficulties I encountered such as the food – too spicy, fatty, salty, no pork – not like in the Philippines.” (JG, Interview 12, Line 15).
Managing Stress through
Rest and Sleep
“The usual day for me… I woke up at 5:30am, prepare my breakfast and prepare my things for school and I spent 7 hours at work from 8-3pm. I have a complete sleep and rest. When I arrived home at 3pm I prepare my lunch and take a nap when there are no deadlines in the school. Sometimes I go out with friends after work. Before I go to bed at 10 or 11pm I usually review or browse my lectures for the following day. During weekends (Friday and Saturday) I do laundry and clean the house and also it’s a time to have a long sleep and rest.” (JG, Interview 12, Line 36-41)
“I usually stay at home to take a rest to rejuvenate my mind. Sometimes, I meditate or listen to good music, or even go to out to dine out with some friends.” (SW, Interview 13, Line 7-8)
“I am having difficulties when it comes to communication to the patients because I can’t speak Arabic so I need my students to interpret what the patients are saying… (JVS, Interview 11, Line 16-17)
“Another challenge I faced is the language barriers. In spite of being here for quite long time, I did not learn the language. I just know some colloquial words used every day. Gladly, the medium of instructions in the university is English but sometimes especially during meetings they will not mind expatriate’s presence… they will do it in Arabic. So, I just don’t mind at all and just get some keywords to catch up to whatever they are discussing. However, some Arabs get conscious and will shift back to English. Haha.” (PL, Interview 15, Line 26-31)
“Having at least a basic knowledge of the language will go a long way helping you practice effectively in a foreign country.” (KF, Interview 10, Line 4)
“It’s a mixture of happiness and disappointment sometimes. Happiness because I get to touch state of the art equipment for teaching, the salary is much higher than in the Philippines, new environment, new found friends etc. Sometimes it’s disappointing because of the people you deal with like colleagues (other nationalities - simple instructions they can’t get, simple things they make it complex) and students (generally speaking they are not as sharp as Filipino students they are much pampered everything is spoon-fed.” (MA, Interview 1, Line 3-5)
“It is indeed challenging. It is like finding the best position to harmonize, approximate, reconcile two ends – two culture, two standards, two systems/process and so forth. In doing so, it entails conducting yourself with high degree of professionalism, keeping up with the demands and pacing of works and upholding the Filipino brand of nursing academicians.” (MS, Interview 3, Line 1-3)
the Core Values
“I think the whole experience of living and working in the Middle East equips me with grit and perseverance and humility to get through the worst experiences that I had like being away from my loved ones and handling stressful situations by myself.” (ADC, Interview 16, Line 14)
“Accepting a totally different life that I am used to as compared to when I was in my home country.” (TLA, Interview 7, Line7)
“Because of my positive outlook I always have good relationship with my colleagues, and superiors even to all of my previous employers.” (SR, Interview 8, Line 16)
“Working abroad as Nurse Educator has a lot of joys and challenges. I can say that it is not easy as we think when we are in a new country it’s not all sunshine and rainbows. The process of adapting may not be easy, but once you have overcome these obstacles, you will find that the experience will have greatly enhanced your confidence in your ability to solve problems and deal with challenging circumstances. You learn that you are much more capable of tolerating discomfort, as well as communicate with and understand people with different upbringings and value systems. These are all very valuable skills to bring home with you, and will be extremely beneficial for your career and your own personal growth. I believe that through my perseverance I conquered everything… and not giving up knowing that the world can be both friendly and rough sometimes. You must enjoy the life that you have at the moment, the more experience you gain the more mature you become.” (JG, Interview 12, Line 50-55)
“Self- discipline and commitment play important roles in giving time to everything that you need to accomplish. Just do it and before you know it, everything was done properly.” (TLA, Interview 7, Line 11-12)
“In my experience, I need to critical thinker and motivate my student first then let them learn how to appreciate the value and importance of education particularly the specific course that I’m teaching them.” (SR, Interview 8, Line 28)
“As a nurse educator living and working in a foreign country I can say that no matter how mentally prepared you are, there will always be unforeseen challenges that could frustrate you especially when they all happen at the same time. It takes a lot of introspection, resilience, and the courage to smoothen the transition. And this learning process alone can be one of the most rewarding experiences you will have.” (JG, Interview 12, Line 44-46)
“I surrounded myself with people with positive outlook in life. In that way, I will be influenced to do the same.” (RJB, Interview 4, Line 31-32)
“Of course my family in the Philippines and Australia. Whenever I miss them, I can call them anytime through Facetime and messenger. Here in the kingdom, my university workmates and church mates. I have also my foster parents here, Tay Randy and Nay Lydia… that takes cares of me and treated me as their own child. I am very fortunate I have their supports.” (PL, Interview 15, Line 45-47)
“Cultural Differences… living abroad had shaken the old habits and routine both mental and physical that you feel most comfortable with. You need to follow or stick to certain habits from body language, social and workplace interaction. “ (JG, Interview 12, Line 16-17)
“Every time you go out you need to wear Abaya and headscarf. There is different section for male and female for the restaurant.” (JG, Interview 12, Line 23-24)
“It made me believe that everything that I have heard from people about bad things in Saudi Arabia changed. I can attest to it.” (PL, Interview 15, Line 81-82)
“The climactic and atmospheric conditions are not big issues since they can just stay at home during rain of ice or sand storm. The weather may suck sometimes; this country is one of the best home for every family.” (MA, Interview 2, Line 49-50)
“More of the advantages than disadvantages because receiving a lot here financially and have a comfortable working condition and facilities than the Philippines.” (SS, Interview 5, Line 9)
“It is very rewarding in terms of financial gain as I receive good salary grade as a nurse educator in the Middle East.” (YG, Interview 14, Line 1)
“Aside from it, I have a church group here in the kingdom. Every Friday, we have bible studies and fellowship services, which I believe contributed a lot for me to be humble at all times. This support group made me feels that I am not alone here… I fell the warm hugs of my family whenever I am with them.” (PL, Interview 15, Line 42-44)
“Listening to preaching of Grace preachers/teachers, reading/meditating scriptures, studying worship songs, managing church itineraries, doing household chores, baby-sitting, etc.” (MS, Interview 3, Line 18)
New Legal Environment
“Life here in Saudi is too enclosed with rules and regulations. There are so many things prohibited and prevented like we cannot talk to females. Alcohol and parties are not allowed. No pork and other products not allowed in the Muslim religion. We are also prohibited to conduct religious activities and so many more. There are times I feel I cannot breathe because of these rules and regulations, which I missed a lot in the Philippines.” (PL, Interview 15, Line 64-68)
“Expat living in foreign country has no freedom to do things they want to do. They need to abide the rules to maintain good status.” (LMC, Interview 19, Line 6-7)
High Sense of Professional
“In terms of work responsibility, I consider it lighter workload as compared with my previous job in the Philippines.” (YG, Interview 14, Line 2)
“I’d love myself to see my names being acknowledged by those whom we had share momentary experience as Nurse Educator. Love to see they are successful in life and how they do, how they tune themselves to be a fine nurses – all because of you as Nurse Educator (molding them in its fineness).” (JDB, Interview 19, Line 23-24)
|Adjusting to Transcultural Relations in the Workplace||
“Another challenge is relating with various nationalities that each one of them has different approaches in nursing education.” (YG, Interview 14, Line 10)
“At the very beginning, I was hesitant to mingle with colleagues. For some reasons that I might say offensive things in which I'm not aware of. I am very cautious of how I communicate with colleagues and my students because of language barriers. I am also anxious with the manner I deal with them.” (RB, Interview 4, Line 4-7)
“Great, because we can maximize our skills here utilizing the advantage technology and we are well compensated here.” (SS, Interview 5, Line 11)
“Currently, I am taking my Ph.D. to fulfill my own wish to hold a doctorate degree before I turn 40. Ever since I started working in the academe, I told myself that this will be my life forever until I die because it gives me a sense of fulfillment especially when you see your students become successful in their careers. My plan for the next few years is to look for a career in the Philippines whether as a part of the faculty or in a managerial level and I am considering also creating a training center for nurses.” (NB, Interview 20, Line 59-61)
3.1.4. Enriching Religious and Moral Dimension
This wellbeing dimension described how Filipino nurse educators enriched two guiding principles: (a) religion (pertains to religious practices, faith, and devotion) and (b) morality (the science of societal ethics) that embodies the adjustment and adaptation of Filipino nurse educators to a new legal environment. The two elements stated in this dimension were both necessary to an individual because it served as their directorial drivers of determining, doing, and acting on what is right, based on the ethical principles and divine law.
3.1.5. Expanding Professional and Occupational Dimension
This portrayed the wellbeing of the participants in the workplace particularly in terms of: (a) developing and cultivating their job quality standards and ethics (job performance, job satisfaction, work ethics, etc.); (b) adjusting to transcultural relations in the workplace; and (c) personal and professional development (self-confidence, self-esteem, outlooks, contentment, realization, self-fulfillment, and self-actualization). Likewise, it embodied how the participants lived up their dreams and aspirations as well as how they planned for the future either staying in the GCC region or venturing out to another place.
3.2. Creation of Survey Tool
The result of the qualitative investigation generated five thematic domains that were used as survey constructs in the second section of the quantitative tool. The individual survey items were derived from the contextual categories and significant statements seen in Table 4.
(Based and Extracted from the Participants’ Accounts)
|Physical and Physiological Dimension (PPD)||Activities of Daily Living (ADL) and Sustained Instrumental Activities of Daily Living (IADL)
Adapting to a Different Diet
|3||Activities of Daily Living||I do my daily activities with ease.|
|I do not have problems with my activities of daily living such as self-care and elimination patterns.|
|I have time to spend for exercises like walking, jogging or running.|
to a Different
|3||Diet||I eat balanced diet.|
|I always eat on time.|
|I do not smoke or drink alcohol products.|
|Managing Stress and Diseases through Diversional Activities, Rest and Sleep||4||Health Management||I regularly go to the hospital for checking my health status.|
|I easily recognized signs and symptoms of a disease.|
|I engaged with sports and recreational activities.|
|I have 6-8 hours of sleep and rest per day.|
|Learning Dimension (LD)||Managing
|2||Communication||I do not have any problems communicating with people verbally.|
|I easily understand the non-verbal cues of the people I am talking with.|
|2||Cognitive||I am open to new concepts that can be added to my knowledge, skills and attitude.|
|I know my priorities in life.|
the Core Values
|2||Affective||I can come up with fair and just decisions all the time.|
|I easily cope with stressful situations.|
|2||Coping Mechanisms||I can see strengths and opportunities during unfavorable situations.|
|I use my core values in my decision-making.|
|2||Skills||I can easily learn new skills either at home or in my workplace.|
|I can see myself growing with new skills I acquired like creativity and innovativeness.|
|I can easily make friends and start a conversation.|
|I enjoyed moments with my friends and other people I meet.|
|I value my relationship with my family, friends and people I meet every day.|
|2||Socio-Cultural||I am aware of the different cultures, traditions and norms existing in one place.|
|I can easily adapt and adjust with new culture.|
|Environmental Safety||2||Safety||I always feel secured and safe in the social environment I belong with.|
|I always anticipate and prepare for any environmental climate change.|
|I can easily provide my basic needs and wants.|
|I can properly budget my money with all of my expenses.|
|I am financially stable at the moment.|
|Religious and Moral Dimension (RMD)||Engaging in
|5||Religious Practices||I find myself time alone for praying, meditating and appreciate nature.|
|I attend religious activities like fellowship program, bible study, etc.|
|I consult my spiritual philosophies when making decisions.|
|I can easily share my religious practices with others.|
|I believe that human being is a steward of God’s creation.|
New Legal Environment
|5||Morality||I am aware and obediently follow the laws and constitutions in the GCC countries.|
|I always observe human rights.|
|I use my values as my guiding principles in life.|
|I decide based from what I know is right.|
|I listen to other people would have to say and try to learn from it.|
|Professional and Occupational Dimension (POD)||High Sense of Professional
|4||Professional Standards||I always follow the quality standards of my work effectively and efficiently.|
|I manage my time effectively between work and family.|
|I value my professionalism at work.|
|I find my work interesting.|
|Adjusting to Transcultural Relations in the Workplace||3||Workplace Environment||I feel comfortable with my work environment.|
|I feel the support from the people in my workplace.|
|I have smooth relationship with my co-workers.|
|4||Personal and Professional Development||I attend personality development activities like mentoring and coaching.|
|I engage with career development activities like workshops, seminars and conferences.|
|I am contented and satisfied with my current job position.|
This two-part survey consisted of fifty items and called as the ‘Filipino Nurse Educator’s Wellbeing Survey’ (FNEWS), which aimed to assess the five dimensions of the wellbeing of Filipino nurse educators in the GCC region. In part one, it included the demographic profile of the participants (name, gender, age, religion, years of experience, etc.) and in part two, it consisted of the five dimensions of wellbeing. Each survey item described the expectations of the participants’ towards the achievement of ‘highly acceptable’ level of wellbeing. The participants rated the survey items by checking how they perceived and practiced each item. Rating scales were classified as: 5 = highly acceptable, 4 = acceptable, 3 = moderately acceptable, 2 = unacceptable, 1 = highly unacceptable.
The researchers subjected the tool for face and content validity. A total of eight experts facilitated the validation processes. These validators worked in the field of nursing as educators, practitioners, and researchers ranging from 10 to 57 years, with mean years of experience being 35 years, SD±6.4 (n=8).
3.2.1. Face Validity
The researchers instructed the validators to provide qualitative comments, suggestions, and recommendations on how to improve the survey tool based from the given criteria : (1) grammar appropriateness, (2) clarity of survey items, (3) accuracy of spellings, (4) sentence constructions, (5) comprehensible font size, and (6) systematic format of the survey construction. All of the validators agreed that all the survey items met the given criteria. All recommendations were carried out by the researchers for the final draft of the survey tool before administering to the prospective participants.
Moreover, exploring the possibility of social desirability bias, the researchers made sure of the following critical intervention: (1) survey items were properly ordered according to the thematic domain so that participants would not skip sensitive items ; (2) wording and sentence constructions were carefully modified, which would reflect the preferred direction of bias ; 3) the researchers had chosen self-completion mode to prevent the participants from any pressure in answering the survey items, which may result the answers to be more truthful; and finally, (4) researchers made sure that at the beginning of the survey, there was a clause stating that this has to be answered anonymously that would guarantee more honest responses from the participants.
3.2.2. Content Validity Index
The panel of experts was asked to rate each survey item regarding its relevancy to each dimension: 4 - very relevant; 3 – relevant; 2 - somewhat relevant; and 1 – irrelevant. After combining and analyzing the individual results of the experts (n=8), 50-survey items emerged as the final survey items of this quantitative tool. All experts decided that all survey items (n=50) were relevant to the thematic domains, thus, the initially drafted survey items were all retained after being meticulously validated with the relevancy of high CVI proportion of favorable being of 0.98 (49.01/50) (Table 5).
After complying with all the experts’ suggestions , the researchers immediately conducted pilot testing for reliability, which included internal consistency, repeatability, and interrater reliability. It was done in three ways: email (n=35), paper and pencil (n=35), and a panel of experts (n=8). The pre and post-test samples comprised of Filipino nurse educators (n=35) working in GCC countries. SPSS version 23 was used for statistical measure of reliability: (a) Cronbach’s Alpha = 0.965; excellent internal consistency; (b) test-retest calculated by using interclass correlation coefficient formula = 0.955; highly reliable measure of repeatability, and (c) percentage agreement (PPD=100; LD=100; SD=93.3%; RMD=93.3%; and POD=93.3% with almost perfect level of agreement).
3.3. Quantitative Phase
A descriptive cross-sectional survey was conducted utilizing a simple random sampling to Filipino nurse educators working in Saudi Arabia (n=112). As stated earlier, the survey tool consisted of two parts: (1) demographics and (2) five dimensions of wellbeing. Demographic profiling is essential in conducting a survey tool because it is imperative to know the details of the participants filling-out the survey (Table 6).It also enabled the researchers to determine the actual target audiences in a specific locale.
In analyzing the results, each dimension had survey items (n=10) that were added up accordingly (e.g. physical and physiological dimension = 3.95) and eventually calculated the weighted mean. Weighted mean was used to measure the general responses of the survey samples given in Table 7.
# in Agree
# in Agree
|1||I do my daily activities with ease.||9||1.00||26||I always feel secured and safe in the social environment I belong with.||9||1.00|
|2||I do not have problems with my activities of daily living such as self-care and elimination patterns.||9||1.00||27||I always anticipate and prepare for any environmental climate change.||9||1.00|
|3||I have time to spend for exercises like walking, jogging or running.||9||1.00||28||I can easily provide my basic needs and wants.||9||1.00|
|4||I eat balanced diet.||9||1.00||29||I can properly budget my money with all of my expenses.||9||1.00|
|5||I always eat on time.||9||1.00||30||I am financially stable at the moment.||8||0.89|
|6||I do not smoke or drink alcohol products.||9||1.00||31||I find myself time alone for praying, meditating and appreciate nature.||9||1.00|
|7||I regularly go to the hospital for checking my health status.||9||1.00||32||I attend religious activities like fellowship program, bible study, etc.||7||0.78|
|8||I easily recognized signs and symptoms of a disease.||8||0.89||33||I consult my spiritual philosophies when making decisions.||9||1.00|
|9||I engaged with sports and recreational activities.||9||1.00||34||I can easily share my religious practices with others.||9||1.00|
|10||I have 6-8 hours of sleep and rest per day.||9||1.00||35||I believe that human being is a steward of God’s creation.||8||0.89|
|11||I do not have any problems communicating with people verbally.||9||1.00||36||I am aware and obediently follow the laws and constitutions in the GCC countries.||9||1.00|
|12||I easily understand the non-verbal cues of the people I am talking with.||9||1.00||37||I always observe human rights.||9||1.00|
|13||I am open to new concepts that can be added to my knowledge, skills and attitude.||9||1.00||38||I use my values as my guiding principles in life.||9||1.00|
|14||I know my priorities in life.||9||1.00||39||I decide based from what I know is right.||9||1.00|
|15||I can come up with fair and just decisions all the time.||9||1.00||40||I listen to other people would have to say and try to learn from it.||9||1.00|
|16||I easily cope with stressful situations.||9||1.00||41||I always follow the quality standards of my work effectively and efficiently.||9||1.00|
|17||I can see strengths and opportunities during unfavorable situations.||9||1.00||42||I manage my time effectively between work and family.||7||0.78|
|18||I use my core values in my decision-making.||9||1.00||43||I value my professionalism at work.||9||1.00|
|19||I can easily learn new skills either at home or in my workplace.||9||1.00||44||I find my work interesting.||9||1.00|
|20||I can see myself growing with new skills I acquired like creativity and innovativeness.||9||1.00||45||I feel comfortable with my work environment.||9||1.00|
|21||I can easily make friends and start a conversation.||9||1.00||46||I feel the support from the people in my workplace.||9||1.00|
|22||I enjoyed moments with my friends and other people I meet.||9||1.00||47||I have smooth relationship with my co-workers.||9||1.00|
|23||I value my relationship with my family, friends and people I meet every day.||9||1.00||48||I attend personality development activities like mentoring and coaching.||9||1.00|
|24||I am aware of the different cultures, traditions and norms existing in one place.||9||1.00||48||I engage with career development activities like workshops, seminars and conferences.||9||1.00|
|25||I can easily adapt and adjust with new culture.||9||1.00||50||I am contented and satisfied with my current job position.||9||1.00|
Total Favorable =
Proportion Favorable =
In interpreting the results, the values were referred to the standard 5-point Likert scale with its pre-determined range and interpretation : (1) Highly Acceptable = 4.21-5.0; (2) Acceptable = 3.41-4.20; (3) Moderately Acceptable = 2.61-3.40; (4) Unacceptable = 1.81-2.60; and (5) Highly Unacceptable = 1.0-1.80. The results were ranked from highest to lowest with its corresponding interpretations: (1) RMD = 4.31; highly acceptable; (2) LD = 4.26; highly acceptable); (3) POD = 4.11; acceptable; (4) SD = 4.06; acceptable; and (5) PPD = 3.95; acceptable. The combined total weighted mean of the participants (n=112) was 4.14. Therefore, the researchers concluded that the overall level of wellbeing of the Filipino nurse educators’ in Saudi Arabia was ‘acceptable’ that clearly answered the third research question.
4.1. The wellbeing of Filipino Nurse Educators
Although a review of the literature stated that nurse educators can straightforwardly amend to a new environment, adaptation varies from person to person . Human adaptation had always been dependent on the individual’s capacity to be accustomed and accept various culture and value system of a certain environment. Yet, research had predetermined judgments on the knowledge indispensable for nurse educators teaching at the tertiary level. There was no literature on gauging prospective Filipino nurse educators’ realization in terms of wellbeing in foreign countries predominantly in the GCC region. However, there was some published research reconnoitering the role of nurse educators abroad but the countless aspects of wellbeing have not been included and discussed in the study.
All the thematic dimensions, (1) Physical and physiological; (2) Learning; (3) Social; (4) Religious and moral; and (5) Professional and occupational, when combined together, would summarize the wellbeing of the Filipino nurse educators in GCC region. Being in a foreign country may have different outcomes depending on how a person deals and accepts changes. For some people, this may lead to detrimental effects on the physical and physiological wellbeing of an individual . In this study, all participants showed ‘acceptable’ healthy living practices and lifestyles, which were evidently seen on their individual accounts and generalized quantitative responses with ‘acceptable’ level of wellbeing (PPD=3.95). However, compared to the remaining four wellbeing measures, it was the lowest. The participants stressed out that due to lack of time and extremes weather changes (extreme hot weather condition), they were not able to do some exercises and other physical activities. Instead they found them spending the rest of their time in the mall, staying at home, and eating out in the restaurants.
From the participants’ accounts and based on the result of the quantitative survey for the learning dimension, majority of the participants agreed that their experience helped them a lot in developing and acquiring new cognitive, affective, and psychomotor skills that they were able to utilize in their activities of daily living (LD=4.26; ‘highly acceptable’) . All participants have positive outlooks as they continue and move forward in achieving their aspirations in life. All core values mentioned in their accounts such as hard work, perseverance, patience, enthusiasm, dedication, etc. made them grounded and protected all possible challenges. They were determined to rise above these challenges in order to provide good life for them and their families.
The participants’ social dimension was one of the lowest with ‘acceptable’ level of wellbeing (SD=4.06) based on the quantitative survey. The results validated the accounts of the participants in the qualitative investigation for having huge impacts in the wellbeing of the Filipino nurse educators particularly in terms of culture, interrelationships, safety and security, and economic stability . The participants mentioned that during their first few years in the GCC region, they faced a lot of struggles such as mild culture shock, stereotyping, discriminations, homesickness, bullying, etc. Instead of giving up, they tried their best to blend with the people, culture and norms, and ways of living. Eventually, they were able to successfully adapt, adjust, and cope with their socio-cultural wellbeing. This had proven that acculturation was essential in their adaption, adjustment and coping process in the GCC region .
As to the participants’ religious and moral dimension, they have shown strong religious uphold and moral awareness even though GCC region had always been an Islamic nation and known for implementing strong cultural practices. The participants remained God-fearing and continuously looked for activities that would show their faith . The participants shared in their accounts that they had been attending fellowship services, mass gatherings, bible studies, and prayer meetings. On the other hand, all participants expressed absolute obedience in exercising government and religious rules and regulations implemented inside the GCC region. Moreover, the participants had stated extreme fear in violating any of the rules due to the abominable punishments that can be implemented to all perpetrators that had been circulated through social media. Some of the activities that were not allowed in the GCC region were as follows: drinking alcohol, kissing and holding hands in the public, sharing with an unmarried partner or having same-sex relationships, and talking of single men and women in public places (specifically in Saudi Arabia). Based from the result of the quantitative survey, the participants have a ‘highly acceptable’ level of wellbeing (RMD=4.31), which reflected that Filipino nurse educators had been religiously and morally obedient permanent residents and cautious in everything that they do since no one will be excused from these legislations.
Lastly, in terms of the professional and occupational dimension, it was evident in the participants’ accounts the strong conviction and eagerness to achieve their aspirations by showing hard work, dedication, and perseverance in their assigned workloads. Most of the time, the participants worked extra hours without any remunerations. Even though staff development was limited for foreign educators, the participants had taken innumerable personal and professional developments inside and outside the GCC region. These testimonies were validated by the quantitative survey resulting an ‘acceptable’ level of wellbeing (POD=4.11). Likewise, Filipino nurse educators had developed and shown assortment of good qualities like zealousness, high-spirited, cheerful, patient, and honest that enabled them to have smooth personal relationships with others . Finally, their excellent work ethics guided them to acquire good working relationships, increased commitment and job satisfaction leading to self-contentment .
4.2. Research Limitations
Face and content validity were done; however, construct validity was not implemented due to the limitation of possible participants for this validation process. The researchers contemplated it as the most significant characteristic of validity as survey items generalized and measured should see the relationship with other variables. Consequently, if they are not correlated, it may prop up prospective prejudices in the construct. Future research may also include the rest of the GCC countries not only focusing on one country.
|Theme Construct||Survey Item||Weighted Mean||Interpretation|
|I do my daily activities with ease.||3.82||Acceptable|
|I do not have problems with my activities of daily living such as self-care and elimination patterns.||4.12||Acceptable|
|I have time to spend for exercises like walking, jogging or running.||3.78||Acceptable|
|I eat balanced diet.||3.92||Acceptable|
|I always eat on time.||3.82||Acceptable|
|I do not smoke or drink alcohol products.||4.40||Highly Acceptable|
|I regularly go to the hospital for checking my health status.||3.74||Acceptable|
|I easily recognized signs and symptoms of a disease.||4.05||Acceptable|
|I engaged with sports and recreational activities.||3.80||Acceptable|
|I have 6-8 hours of sleep and rest per day.||4.02||Acceptable|
|I do not have any problems communicating with people verbally.||4.02||Acceptable|
|I easily understand the non-verbal cues of the people I am talking with.||4.18||Acceptable|
|I am open to new concepts that can be added to my knowledge, skills and attitude.||4.32||Highly Acceptable|
|I know my priorities in life.||4.48||Highly Acceptable|
|I can come up with fair and just decisions all the time.||4.28||Highly Acceptable|
|I easily cope with stressful situations.||4.12||Acceptable|
|I can see strengths and opportunities during unfavorable situations.||4.32||Highly Acceptable|
|I use my core values in my decision-making.||4.38||Highly Acceptable|
|I can easily learn new skills either at home or in my workplace.||4.25||Highly Acceptable|
|I can see myself growing with new skills I acquired like creativity and innovativeness.||4.30||Highly Acceptable|
|Total||4.26 (Highly Acceptable)|
|I can easily make friends and start a conversation.||3.82||Acceptable|
|I enjoyed moments with my friends and other people I meet.||4.08||Acceptable|
|I value my relationship with my family, friends and people I meet every day.||4.30||Highly Acceptable|
|I am aware of the different cultures, traditions and norms existing in one place.||3.72||Acceptable|
|I can easily adapt and adjust with new culture.||3.74||Acceptable|
|I always feel secured and safe in the social environment I belong with.||3.88||Acceptable|
|I always anticipate and prepare for any environmental climate change.||3.92||Acceptable|
|I can easily provide my basic needs and wants.||4.45||Highly Acceptable|
|I can properly budget my money with all of my expenses.||4.30||Highly Acceptable|
|I am financially stable at the moment.||4.48||Highly Acceptable|
|I find myself time alone for praying, meditating and appreciate nature.||4.52||Highly Acceptable|
|I attend religious activities like fellowship program, bible study, etc.||4.32||Highly Acceptable|
|I consult my spiritual philosophies when making decisions.||4.62||Highly Acceptable|
|I can easily share my religious practices with others.||3.92||Acceptable|
|I believe that human being is a steward of God’s creation.||4.22||Highly Acceptable|
|I am aware and obediently follow the laws and constitutions in the GCC countries.||4.52||Highly Acceptable|
|I always observe human rights.||4.18||Acceptable|
|I use my values as my guiding principles in life.||4.58||Highly Acceptable|
|I decide based from what I know is right.||4.08||Acceptable|
|I listen to other people would have to say and try to learn from it.||4.12||Acceptable|
|Total||4.31 (Highly Acceptable)|
|I always follow the quality standards of my work effectively and efficiently.||4.28||Highly Acceptable|
|I manage my time effectively between work and family.||4.12||Acceptable|
|I value my professionalism at work.||4.18||Acceptable|
|I find my work interesting.||3.98||Acceptable|
|I feel comfortable with my work environment.||4.08||Acceptable|
|I feel the support from the people in my workplace.||3.82||Acceptable|
|I have smooth relationship with my co-workers.||4.12||Acceptable|
|I attend personality development activities like mentoring and coaching.||3.86||Acceptable|
|I engage with career development activities like workshops, seminars and conferences.||4.26||Acceptable|
|I am contented and satisfied with my current job position.||4.36||Acceptable|
|Grand Total (N = 50)||4.14||Acceptable|
4.3. Implications and Way Forward
The possibility of using this survey tool for Filipino nurse educators in other GCC countries may also be recommended. Conceptualization of a well-structured and robust program for nurse educators desiring to work overseas should be strategized and implemented, which includes expanded orientation programs embracing personality development, communication and language, cultural awareness, and civil laws. Moreover, creative activities and outlets must be offered by the Philippine consulate partnered by the Filipino nursing organizations based from the identified wellbeing dimensions such as: sports festivities, weekly exercise programs and monthly health check-ups (physical and physiological); competency development such as language training, personality development and new skills acquisition (learning); socio-cultural gatherings and entertainment (social); spiritual retreats and fellowships (religious and moral); and personal and professional training courses and continuing education (professional and occupational).
The outcome of this mixed methods study served as evidence that Filipino nurse educators in spite of various life challenges had remained steadfast. They were willing to continuously strive harder to achieve their aspirations and attain good life not only for them but for their families. Physical and physiological (PPD = 3.95) and socio-cultural (SD = 4.06) dimensions garnered the two lowest wellbeing dimensions in the quantitative survey. In spite of being the lowest, these dimensions both remained in the ‘acceptable’ level of wellbeing. These challenges experienced by the participants will continue to affect the total wellbeing until no modifications and improvements will be done (e.g. lifestyles, point-of-views, etc.). This study will provide awareness on how to increase wellbeing and will be added to the existing body of literature about wellbeing that commonly mentions factors contributing to unsuccessful adaptation, burnout, compassion fatigue, and decrease in job satisfaction. It is also significant to keep in mind that financial gains as stated in the participants’ accounts would not always be the purpose why professionals seek job opportunities abroad. Majority of Filipino nurse educators’ expressed their intentions to seek job opportunities overseas because of personal and professional developments, broadening their academic horizons, cultivating one’s acquisition of new competencies, and competitive career opportunities.
Lastly, this survey tool in its totality had established sufficient and standard measurement performance in conducting quantitative studies in assessing the wellbeing of Filipino nurse educators in the GCC region. Each thematic dimension emerged from the qualitative results symbolized a noteworthy responsibility in attaining the Filipino nurse educator’s optimal wellbeing. All of these dimensions were interrelated and interconnected, which means that if one dimension will not be met then other dimensions will be affected too. In fact, the personal accounts of the participants were validated by the result of the quantitative investigations resulting in an ‘acceptable’ level of wellbeing.
ETHICAL APPROVAL AND CONSENT TO PARTICIPATE
Ethical approval was granted by the Institutional Ethics Review Committee of SPUM University.
HUMAN AND ANIMAL RIGHTS
No animals were used in this study. All human research protocols were in accordance with the ethical standards of international and national human experimentation committee with the Helsinki Declaration (2013).
CONSENT FOR PUBLICATION
Written informed consent was signed by the participants of the study prior to publication.
AVAILABILITY OF DATA AND MATERIALS
The data that support the findings of this study are available from corresponding author upon request.
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.
The researchers would like to thank Mrs. Kathlyn Kaye Sanchez for patiently proof-reading the manuscript. Secondly, to Mr. Ben Ryan Sauce, Mr. John Cabrito, and Mr. Edison Dorado for helping the researchers in the data encoding. Lastly, to Dr. Jerry Manlapaz for his valuable inputs and recommendations on how to improve the study.
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