Joumal of Advanced Nurstng, 1992,17,1129-1140

Continuing professional education forqualified nurses: a review of the literature

K Louise Bamball BA RGNResearch Asststant

Alison E While BSc MSc PhD RGN RHV Cert EdSentor Lecturer

and Ian J Norman BA MSc RMN RGN RNMH Dip App Soc Shid CQSWLecturer, Department of Nurstng SttAdtes, Ktng's College, Untverstty of London, London,England

Accepted for publication 27 January 1992

BARRIBALL K L, WHILE A E & NORMAN IJ (1992) Journal of Advanced

Nurstng 17 ,1129-1140Continuing professional education for qualified nurses: a review of theliteratureReviewed bterature identifies the importance of contmumg professionaleducation and professional development for nurses subsequent to irutialregistration (mcludmg enrolled nurses) However, there is a lack of empincallybased work analysmg nurses' perceptions of their contmumg professionaieducation needs and the perceived outcomes of contmumg professionaieducation m terms of changes m knowledge accretion, attitudes, sblls, jobsatisfaction, stafif retention and career development It is suggested that this lackof empincal work needs to be addressed if the proposed plans of the UnitedKingdom Council for Nursmg, Midwifery and Health Visiting (UKCC) tointroduce mandatory contmumg professionai education are to have maximumbenefits for chents, nurses and the service

BACKGROUND practice Imphat m these is the notion that, not only musteach nurse be competent to register, but he/she must also

The importance and relevance of contmumg professionai ^^^^ competent after registration (Crossfield 1989)educahon to nurses has been repeatedly asserted through- ^^^^^ ^^^ ^_^^^^^^ ^^^ Committee (1981) has arguedout the hterature (e g Shiddy & Hunt 1980, Charles 1982, ^^^^ ^^^^ ^^^^^ ^^ ^^^^ ^^ ^j^^ ^^^ ^^ ̂ ^^^^ ^^

Brown 1988, Stanford 1989, Hunt 1991) and also in many ^^^^^^^ knowledge and skills and cntically assesspieces of legisUhon that address the dehvery of health care ^^^^^^ ^ ^ , ^ ^ ^ g ̂ ^^^ ^^^^ ̂ ^ ^^^^^^^ ^ ^^^ ^^^ ^^

services The Royal Commission on the Nahonal Health p^^f^^^.^^^j Conduct for the Nurse, Midwife and HealthService (1979) desmbed post-basic educahon for nurses as ^^^^^^^ ̂ ^^^ ^^^^^^ ^^^^essenhal and recommended an lnaease in its fundmg as amatter of urgency Each registered nurse, midwife and health visitor is

The Nurses'Rules, embodied in the Nurses'Act (1979), accountable for bs or her practice, and m the exerasestipulated competencies required by nurses for accountable of professional accountability shall take every reasonable

opporturuty to mamtam and improve professionai knowledgeCorrapordoKt K.I BambaU Research Assafant Department of Nurstng Studies, , iKtngs CoUege Univemty of Unubn, CormvaU House Amex, Waterloo Road, and competenceUmdon SBl 8TK England {UKQ.L 1984)

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K.L Bamball ^al

Whilst legislation emphasizes that nurses must ensurethat their practice is satisfactory, it is clear that some nursesdo not update their knowledge by reading professionaljoumals or undertake additional professtonal educationfollowing registrahon (Myco 1980, Bamett 1981, Kershaw1985, Hibbs 1989, O'Bnen & Heyman 1989, Chiarella1990, Fnend 1991) The United Kmgdom Cenfral Counal(UKCC 1990) has responded to this mismatch m theReport of the Post-Registrahon Educahon and PracticeProject (PREPP) which supports linkmg mandatory con-tmumg education with eligibility to practise throughre-registrahon The proposals laid out in the Report aim toensure that professionai standards are mamtamed andimproved throughout the career of each practihoner byredressing the current ldentthed defiaenaes of availablepost-registrahon educahon and professionai developmentopportumties (Fardell 1991, Maggs 1991)

Sidft in emphasis

An increasing number of pohcy direchves advocate ashift m emphasis away from voluntary parhapation tomandatory attendance on approved conhnumg pro-fessional education programmes Important to the out-come of any educahonal programme, however, whethervoluntary or mandatory, is the leamer (Cervero 1985,Jarvis 1987, Peden et al 1990, Hunt 1991) Jarvis (1983)has argued that the aim of professionai educahon shouldnot only be to produce competent practihoners but alsoproduce in the leamer

the abihty to recognise good practice and the determinationto ensure that his own future prachce will not fall below tbsstandard

Through personal professionai profiling, Post-Registrahon Education and Prachce intends that all nurseswiU cnhcally assess their clmical practice and identify theirown contmumg professionai educahon needs However,m a resource-limited environment it is important that dataare available which identify the benefits to nursing ofdifferent educahonai expenences if scarce resources areto be channelled into conhnumg professionai educahonprogrammes matched to ldenhfied needs

The UKCC (1987) has argued that health care dehverywiU need a new type of practihoner who is a 'knowledge-able doer' capable of flexibility and creahvity With this inmmd, it IS important that the resources that nurses perceiveas sigruficant and lnfluoitial m acquiring and developmgtechruques m cnhcal thinkmg and reflechve prachce aredearly understood It is also important to understand how

nurses view contmumg professionai educahon and theirpercephons of its relahonship to nursing, dinical practice,professionai development, job satisfachon, staff retentionand career progress A review of the hterature has revealed,however, a lack of empincal data addressmg these issues,highlighting the need for further research

TOWARDS A DEFINITION OFCONTINUING PROFESSIONALEDUCATION

There is no agreed definition of continuing professionaieducation m the hterature However, an understanding ofwhat continuing professionai educahon entails or ought toentail is important to provide a contextual framework fordebate

Stanford (1989) has argued that continuing professionaieducation should not be defined too narrowly, it mvolvesmore than just attending study days and courses Hisdefimhon emphasizes the achve involvement and motiv-ation of the leamer in developing and expanding his/herknowledge and understandmg through a vanety of meansthat include self-directed readmg In contrast, Hughes'(1990) defimhon has focused upon structured and plannedmcidents such as study days, conferences and shortcourses

Barber (1977) has usefully divided contmumg educationmto two distmct categones (a) informal educahon whichlndudes achvihes such as reading, studymg, watchmgtelevision and workmg on committees, and (b) formaleducation of which seminars, conferences and plannededucational programmes play an important part Jarvis(1954), however, has clearly differentiated betweenlearning and education He has summarized his views thus

Continuing learning assumes that the professional willendeavour to keep abreast of all new developments throughself-direction, by reading and attending conferences Con-hnuing educahon suggests that educahon courses have to besupphed for the practitioner to attend

According to Kershaw (1985), continuing professionaieducahon m the UK has tended to be an all-embraang tenncovermg any learmng expenence that takes place afterlmtial nurse educahon However, Charles (1982) andO'Kell (1986) have argued the importance of distmguish-mg m-service and onentation programmes from otherforms of contmumg professionai education This is becausethe former is largely determmed by the needs of theemployer while the latter provides a framework m whichthe needs of mdividual nurses and the needs of the servicecan be identified and addressed (Duberley 1985)

Continuing professionai educatton

American Nurses' Association

The Amencan Nurses' Association (ANA) has usefullydistmguished contmumg professional education fromm-service educahon or traimng, onentation and staffdevelopment The Association has defined contmumgeducation as

planned educational activities intended to build upon theeducationai and experiential bases of the professional nursefor the enhancement of practice, education, administration,research or theory development to the end of improvmg thehealth of the pubbc

(ANA 1984)

This defimtion does not underestimate the sigmficance oflearning activities outside or beyond planned educationalincidents for ensunng that nurses develop and expand theirknowledge Indeed, a valuable outcome of contmumg pro-fessional education in nursmg would be a demonstrableincrease m informal educationai achvihes such as readmgprofessional joumals (Snell 1987) However, a distmctionbetween self-directed leammg (informal education) andcontinuing professionai education as defined by theANA (1984) IS necessary for the planrung, financmg,implementation and evaluation of mandatory continuingprofessionai education programmes proposed by thePREPP

Voluntary or mandatory provision?

It IS incumbent upon any profession to ensure that itsmembers are responsible and knowledgeable practitionersGarvis 1983) Concem has been aired m the hterature atthe apparent lack of commitment in the UK to continuingprofessionai education by both nurses and health authonties(e g Dodwell 1983a, Kershaw 1985, Rogers 1987, Stanford1989) In recent years, much debate has been focused uponthe issue of voluntary versus mandatory contmumgprofessionai educahon for nurses (eg Charles 1982,Jarvis 1983, Peutz 1983, Hutton 1987, Brown 1988, JuallCarpemto 1991a,b)

In tbe North Amencan hterature comprehensive,mandatory contmumg professionai educahon programmesare inaeasingly advocated as the most effechve andeffiaent way of ensunng that all nurses m practice arekept up-to-date (e g Schoen 1979, Peutz 1983, Thomas1986, Hutton 1987, Weiss-Faman & Willie 1988) TheUKCC (1990) has now firmly recommended mandatoryconhniung professional education for all nurses m the UK

The provision of continuing professional educahon,however, is an expensive undertakmg (Rizzuto 1982, Jarvis

1983) and today's climate of resource restraints highlightsthe need for continuing professionai educahon to becost-effective If the PREPP proposals are implemented,approximately 800 000 woriang days will be lost tostudy leave (Carhsle 1991) Further, a preliminary costmganalysis has estimated the Post-Registration Education andPractice will cost between 50-100 milhon pounds per year(UKCC Press Statement 1991)

Fardell (1991) has argued that value for money withmPREPFs proposed conhnumg professionai educahonprogramme may be judged by whether a nurse's personaleducation and development programme has resulted mimprovements m practice and knowledge and demon-strable professional development On a cautionary note,however. Brown (1988) has argued that the mtroduction ofmiindatory continuing education for nurses should not beseen as the 'panacea to cure the disease of laggards'

Without careful piarmmg and research, mandatorycontinuing professional education is unlikely to deliverthe anticipated development of reflective practice andcnhcal thinking considered cruaal for improved patientcare Indeed, Ho (1984) has argued that while midwifepractitioners have to attend a refresher course every 5years in the UK in order to retain the nght to practice, thisdoes not guarantee that midwives remam up-to-date Shehas noted that attendance at a contmumg professionalevent does not necessanly result m the acquisition ofknowledge and argues that not enough acknowledgementIS generally given to the importance of the relationshipbetween the individual and the learmng process, a pomtalso made by Cooper & Homback (1973) and Cooper(1978) In other words, the desire of the leamer to benefitfrom the leammg expenence is cntical to the outcome ofthe process

THE EXTENT OF PROVISION OFCONTINUING PROFESSIONALEDUCATION IN NURSING

The provision of continuing professional educationin the United Kingdom

The evidence suggests that the provision of contmumgprofessionai education available to nurses vanes enor-mously (Charles 1982, Stanford 1989) Popiel (1977) hassuggested that contmumg professionai educahon mnursmg needs nahonal, regional and local organization morder to provide an effechve and ef&aent programmeHowever, httle co-ordmahon even at local level currentlyexists As Carhsle (1991) has pomted out, some healthauthonhes have well-estabhshed contmuir^ professional

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K.L Bamball etal

education programmes while others appear to have httlecommitment or mtent towards providing a comprehensiveprogramme In part, this may reflect the way m whichcontmumg professionai educahon is financed, for manyhealth authonties it is a marginal activity and as suchallocated paltry stuns

Rogers' (1987) survey of all distnct health authonhes inEngland and Wales revealed disturbingly limited con-tmumg professionai education opportumhes for nursesworiang m clmical areas (she mduded m-service trammgwithin her defimhon of conhnumg professionai educahon)Only 58% of distnct health authonhes daimed to have aphilosophy of conhnumg professionai educahon m theform of a wntten statement and only 29% of all distnctscommunicated this philosophy to qualified nursing staffFurther, there was a considerable gap between expressedcommitment to continuing professionai education byhealth authonhes and the extent to which this commitmentwas demonsfrated in prachce

Chiarella (1990) has suggested that the apparent lack ofcomnutment to conhnumg professionai education fromsome qualified staff can be attnbuted m large measure tolade of opportimity Indeed, a repeated theme m thehterahire is concem over the inadequate provision ofcontmumg professional education generaDy available tonurses (e g Refers 1983b, Rogers 1987, Stanford 1989)

A lack of fundmg is fi^quently ated as the majorcontnbutmg factor (e g Charles 1982, Lathlean & Famish1984, Hicken 1990) However, finanaal difficulhes do notadequately explam why some health authonhes are ableto offier relahvely extensive contmumg professionaieducahon programmes to nurses and others are not Littleinformation is available on coshng analyses and theabsence of cost-benefit analysis and other coshng data is amajor gap m the UK hterature

to the questionnaire was very poor; 21% compared to aresponse rate of 74% from day staff In discussmg theirfindings, Clarke & Rees suggest that mght staff may havehad httle access to contmumg professionai educahon andso did not feel that the questionnaire was relevant for them

Although 63% of those retummg a queshonnaire(« = 100) said that they had attended a study day withmthe preceding year, non-responders (« = 78) might nothave attended anything Indeed, response rates werehighest from midwifery sisters who were three hmes morehkely to attend a contmumg professional educahon eventthan staff midwives Further, 70% of the community mid-wifery sisters in the sample (M = 21) had not attended acourse or study day m over 12 months

While there may be several reasons why differentcategones of staff are less likely to complete questionnairesthan others, there appears to be a relahonship betweenthe degree of mvolvement in contmumg professionaleducation and response rates In a random sample ofquahfied nurses (n = 226), Studdy & Hunt (1980) foundthat just over 30% of enrolled nurses who completed theirqueshonnaire had attended a study day withm the previous12 months In contrast, 75% of sisters had done so Theresponse rate from enrolled nurses was particularly disap-pomtmg, 35% compared with 94% for nurse teachersShiddy & Hunt (1980) also found that 24% of their sample,mainly enrolled and staff nurses, had never attended acourse or study day since they quahfied, although theygive no details about quahfying dates

The findmgs of the above studies are supported byLarcombe & Maggs (1991) who also found that the pro-vision of contmumg professional education opportunihesfor mght staff and enrolled nurses were considerably fewerthan for day staff and more semor nurses One enrollednurse summanzed her situahon thus

The leveb of access to continuing professionaleducation by qualified nurses

Few national statistical data exist about the numbers ofnurses receivmg or partiapahng m contmumg professionaleducahon programmes Most data reviewed are denvedfrom rdahvely small surveys often on one health authontyHowever, there are particular difficulhes analysing andinterprehng the stahshcal data from these studies (Clarice1989)

Qarice & Rees (1989) have suggested that data collectedfrom mterview and queshonrtaire surveys of nurses may notreflect the extent to which all nurses gam access or partia-fKtte m contmumg professionai educahon programmes Intheir postal survey of 178 midwives, night staff response

They sometimes forget us If there are five staff nurses, we getleft out

Larcombe & Maggs (1991) have contended thatrestnchons of finance and availability of places on coursesfrequently mean that the needs of more semor staff aregiven pnonty Nugent (1984) found that 72% of psy-duatnc nurses (n = 17) and 60% of general nurses (« = 27)m his study ldenhfied ward sisters/chai^e nurses asbenefihng most from fiirther traimng opportimihes, sug-geshng po-haps that the unequal access by d^rent gradesof staff to contmumg professionai education is justified and^propnate Further, Famish (1983) has tonmd from hersurvey that ward sisters («=166) were not ackquateiy

1132

Continutng professtonal educatton

prepared for their roles and were generally m need ofconhnumg professionai development and education

Adjusting to new rolesUthlean (1987) and Shand (1987) have identified how-ever, that newly quahfied nurses expenence particulardifficulties adjustmg to their new roles Lathlean's (1987)queshonnaire study revealed that 95% of staff nurses(M = 96) felt that they needed to know more about wardmanagement

The staff nurses (n = 20) interviewed by Shand (1987)also identified a wide range of topics, includmg meinage-ment and teachmg sbUs, in which they did not feelcompetent Moreover, Comer's (1990) study of the newlyregistered nurse and the cancer patient has revealed that,while 91 2% of nurses (« = 127) cared for cancer patients atleast occasionally, 82% rated their own comp)etence to carefor pahents with cancer as low

Lathlean (1987) has suggested that the failure to providecontmumg professionai education opporttmities aimedspecifically to meet the needs of newly quahfied staffcontnbutes to nurses leavmg at this cnhcal time Indeed,Mackereth (1989) has argued that failure to provideadequate contmumg professional education opportumhes toall members of staff may have imphcahons for job sahsfachonand retention rates There is, however, a gap in the hteraturewith few empincally based data explormg these issues

CONTINUING PROFESSIONALEDUCATION AND NURSES

The views of nurses

It has been cogently argued that the leamer's commitmentto leam and benefit from an educahonal expenence isparamount m professional educahon (Knowles 1978, Jarvis1983, Alexander 1984, Ho 1984, Cervero 1985) Theviews of nurses are, therefore, important and must beacknowledged and reflected m programmes if they are tofoster and develop nurses' commitment and enthusiasmfor conhnumg professional education (e g Clarke & Rees1989, Mackereth 1989)

Whilst continuing professionai educahon has attractedhmited research mterest m the UK, there are six surveyswhich contnbute to an understanding of nurses' viewsNmety-five per cent of the sample (n = 226) m Studdy &Hunt's (1980) survey considered conhnumg professionaieducahon to be desirable and 63% thought it was essential

Madcereth (1989) undertook a small questionnairesurvey <rf staff nurses (n = 70) woriang m three Londonhospitals He found that just over 60% valued their con-hnumg professional or general educahon Engh^ National

Board (ENB) courses were parhcularly popular althoughseveral staff nurses were also senously considenngundertakmg both nursing and non-nursing degreesSeventy-eight per cent expressed a desire to pursuefurther educahonal opportumties Job promotion, personalgrowth, updating, interest and mcreased knowledge andskills were among many reasons given for considenngundertaking further courses

Clarke & Rees (1989) also found a recogmhon amongmidwives of the importance of post-registration education.Ninety-mne per cent of midwives (n = 100) who com-pleted their questionnaire felt that there was at least someneed, if not a great need, for post-registrahon midwiferyeducahon, although 75% said they would be reluctant toattend courses in their own hme

Lmdsay's (1990) survey which assessed the demandfor continuing professionai education amongst nurses(n = 610) foimd a strongly positive attitude Interest infurther study was expressed by 81% of respondents Of the208 enrolled nurses included in his survey, 162 (78%)hoped to attend at least one further course ENB courseswere agam particularly popular, with 58% wishmg to doone or more courses Of those givmg family comrmtmentsas a reason for havmg no immediate plans to parhcipate in acontinuing professionai education programme, manyindicated a desire to do so once their children were older

Nugent (1990) conducted a questionnaire study among100 first-level nurses working withm one health authonty todiscover the extent to which nurses were aware of the needto conhnue their educahon followmg registrahon Linkmgcontmumg professionai educahon with registrahon wassh-ongly supported by 79% of staff nurses (n = 29), 85% ofsisters (« = 60) and 81% of charge nurses (n = 11) Further,93%, 85% and 82% respechvely did not feel that mihal nurseframmg was suffiaent for a life tune of prachce Nugent

(1990) conduded that, perhaps contrary to popular assump-hons, nurses m the UK are increasingly developmg a strongcommitment to, and a recogmhon of, the importance ofcontinuing professionai education

Indeed, all respondents (n = 105) m Larcombe & Maggs'(1991) interview survey said that they were interested intheir continuing professional education although three hadnot parhcipated in a planned educational inadent for morethan 2 years In the light of such vanable evidence, moredetailed analyses of nurses' views towards contmumgprofessional educahon are needed

The identification of nurses' continuii^ professionaleducation needs

O'Kell (1986) and Mackenzie & Sims (1989) have assertedthe importance of ldenhfymg nurses' educahonal and

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K.L Bomiw//etal

development needs if contmumg professional educahonexpenences are to be effechve This reflects both the issueof mohvahon to leam as well as a recogmhon that thereare times when particular contmumg educahon needs areapparent and require a speafic programme to meet them(Mackenzie & Sims 1989)

Larcombe & Maggs (1991) have argued that the idenh-fication of a need for continuing professionai educationIS an essential part of the 'continuum of professionaldevelopment' and pomt out that

Without an effective system for identifying a need, theprovision of conhnumg professionai education remamsarbitrary, random and mequitable

The UKCC Code of Professionai Conduct (UKCC 1984)states that it is the responsibility of all nurses in practicenot only to monitor and improve their knowledge but alsoto acknowledge lmutahons and seek out instruction andassessment m order to mamtam and develop competenceto prachce

Rogers & Lawrance (1989) have descnbed needs relatedto professional, personal, dmical and orgamzational needand have argued that the ldenhfication of need is a complextask This pomt is supported by Orme & Tnckett (1983)who have mdicated that a sigmficant problem m conhnumgprofessional educahon is the difficulty nurses have ldenh-fsnng their contmumg professionai educahon needs Theyhave suggested that it is unsound to rely upon what nursesrequest because it may be the case that what nurses wantand what they need are two different things

In their queshonnaire survey of 36 ward sisters/chargenurses, Orme & Tnckett (1983) found that, while the needfor climcal updahng was given pnonty when choosingfurther trairung requirements, difficulties in managing staff,communicahon problems and counsellmg skills were fre-quently identified as the problems encountered in theirdaily woric

Need

Larcombe & Maggs (1991) have usefully analysed thedifferent mterpretahons and uses of the word 'need' withmcontmumg professional educahon m the hterature,drawmg a dishnchon between prachhoners' wants andthe needs of the organizahon They highlighted theimportance of the partnership between mdividual nursesand employmg authonhes in develc^mg prc^ranmes ofcontmumg profesaonal educahon that address both the

ldenhfied needs of nurses and the service, a pomt also madeby Lathlean (1986) Brackaus (1984) has suggested, how-ever, that since it is the individual leamer and not theorganizahon that leams, it is the needs of the mdividualwhich must be ldenhfied and met

Nugent (1984) has assessed the needs, as perceivedby staff, of their in-service traming requirements Hisqueshonnaire survey revealed that 52% of general nurses(n = 27) and 47% of psyduatnc nurses (M= 17) felt thatdevelopment of chnical expertise best suited theirneeds although management skills were also consideredimportant

Pamaby (1987) has surveyed the opimons of midwives(M = 117) and semor midwifery tutors (n = 149) regardingthe cumculum content of refresher courses Out of the45 topic items m the questionnaire, 14 were rated to beessenhal cumculum content by over 50% of respondentsNine of these topics were directly linked to dimcal practice

Clarke & Rees (1989) also found that midwives showedgreatest mterest m topics that were directly related to dmi-cal prachce, although they agam showed keen mteresttowards updahng management skills

Shiddy & Hunt (1980) found that, for the majonty (76%)of nurses in their sample (n = 145), the course content wasthe most important factor mfluencmg attendance Cooper(1978), Heick (1981) and Brown (1988) have arguedthat this IS because it is of paramount importance thatthe leamer within continuing professionai educationperceives the relevance of the content of an educahonprogramme to his/her job or to personal or professionaidevelopment

Nugent (1984) found, however, that many of the 44respondents m his study were undear about the benefits ofattendmg m-service lectures McCrea (1989) also foimdthat 66% (n = 43) of midwives in her semi-structuredqueshonnaire study felt that the statutory refresher coursesfor midwives only partly met their contmumg professionaieducahon needs Further, Larcombe & Maggs' (1991)detailed study found that 29 of the 370 contmumg pro-fessional educahon events attended by 102 nurses withinthe previous 2 years were perceived to be mappropnate totheir identified needs

The evidence suggests that there are weaknesses m theprocesses for ensunng that the ldenhfied contmumgprofessionai educahon ne«ls of nurses are met However,failure to meet these needs has imphcations for theeffiaency and cost-effechveness of contmumg professionaiediKahon programmes Withm today's ecorKMmc dunate,an acrurate match between nurses' conhnumg profes-sional educahcm needs and the provision of contmuir^professional education events is important

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Continuing professionai educatton

Factors affecting uptake

A common findmg is the lack of informahon pertammg tothe availability of conhnumg professional education How-ever, a few studies have revealed that nurses expenencespecific difficulties accessing conhnumg professionaleducation events Clearly, these difficulhes need address-ing to ensure maximum uptake of contmumg professionaieducation opportumhes by all qualified nursing staff

Studdy & Hunt (1980) found that course attendance wasstrongly mfluenced by early notification of contmumgprofessionai educahon events and permission to takestudy leave as well as the content of the course Althoughthe timmg of courses was not seen to be of particularimportance, mid-week scheduling was viewed as moreconvenient and 57% favoured half-day study sessionsrather th<in a full-day timetable Half-day, mid-weeksessions were also the most popular scheduling identifiedby Dodwell (1983b) m her random Scimple of quahfiednurses (M = 311)

Lathlean & Farmsh (1984) found that inadequate advancepublicity promotmg m-service traimng events for wardsisters/charge nurses hindered uptake due to the difficultiesencountered with changmg off-duty and ensunng that theward was safely covered at short nohce Other importantfactors were the lack of Bntish National Health Service(NHS) finance and encouragement from management

McCrea's (1989) survey of 43 midwives m NorthemIreland also found that the athtude of managers towardscontmumg professional education was significant Staffinglevels were identified as creahng difficulties for secunngtime off, and part-time staff commented on the particularproblems they expenenced obtaining study leave Thismay partly explain why few had requested to attenda continuing professionai educahon event Only twomidwives who had requested to attend a continuing pro-fessional education event (n = 12) described their managersas highly encouraging Three stated that their managerswere indifferent

Lack of literature

Lack of suitable hterature and vague mformahon about theimportance, sigmficance and availability of continuingprofessionai education opportunihes were indicated bystaff nurses (n = 70) and second-year student nurses(n = 75) m Mackereth's (1989) queshonnaire survey Asignificant number (36%) of the staff nurses also reportedthat they had received no information or guidance aboutpursuing their contmumg professionai educahon

The staff nurses parhcularly complamed of the problemsencountered with managers and their lack of support and

encouragement, negative athtudes from some managershave also been reported by Heath (1980) and Lahiff (1984)Mackereth's (1989) respondents daimed that attendanceon continuing professional education events was oftenmade difficult or impossible by poor staffing levels or lackof available funds These were also identified as recurrentbamers to pursumg continuing professionai educahon byComer (1990) and Larcombe & Maggs (1991)

Schoen (1979) has emphasized the importance ofacknowledging that responsibihhes other than educationcompete for a leamer's time and energy The demands ofthe service and domestic commitments may deter nursesfrom parhapatmg in continuing professionai education asmay stress, tiredness and other distrachons (Brown 1988)

Three studies have highlighted the impact of domeshcresponsibihties on nurses' response to contmumg pro-fessional education opportumties Taking a random sampleof 600 queshonnaires from a total of 8142, Rogers (1983b)found that family commitments were acknowledged bymany qualified nurses as restnctmg their ability to attendcourses These findings were supported by Lindsay (1990)m his survey of 610 qualified nurses Larcombe & Maggs(1991) have ldenhfied that special difficulhes confrontnight staff and part-time nurses because of their domeshcarrangements and pomt out that these ought to be takeninto consideration when plannmg contmumg professionaleducahon events

A review of the hterature suggest little explorahon ofwhat nurses want or need in terms of timing, length andlocation of course so that they can meet their otherresponsibihties Tbs is a surpnsmg omission in the lightof increasing recognition of the sigmficance of consumerviews generally and more speafically the importance of theViews of learners

OUTCOMES OF CONTINUINGPROFESSIONAL EDUCATION

Impact on patient care

Popiel (1969) has suggested that two important outcomesof conhnumg educahon should be leammg new roles,techniques or skills and the acquisition of knowledge, sfallsand attitudes that will enable nurses to perform m thepractice settmg This reflects a repeated assertion m thehterature that continmng professional education ought toimprove patient care (e g Mitsunaga & Shores 1977, Heick1981, Dodwell 1984, Crotty & Bignell 1988, Maggs 1991)In spite of this, a review of the literature suggests thatcomparahvely little attention has been paid to the effect ofprogrcimmes on nursing practice and whether or not they

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K.L BamlmUeid

are effective for ensunng competaux (eg Greaves &Loquist 1983, Ho 1984, Bignell & Crotty 1988) Withmthe present era of accountabihty and quahty assurancethroughout the NHS, this se«ns a surpnsmg omission(Bignell &Qotty 1988)

Evaluative work has been camed out m the USA (e gHeick 1981, Greaves & Loquist 1983, Cervero 1985, Farley1987, Meservy & Monson 1987, Wannuth 1987, Fenrell1988), but Hutton (1987) has conduded from her review ofthe hterature that research studies of the relahonshipbetween contmumg professional educahon and enhanceddimcal practice m nursmg are mcondusive

Indeed, as Snell (1987) has pomted out, a current debatein the USA concems how to translate conhnumg pro-fessional education mto the work settmg and how to defineits impact on chmcal prachce, a point also made by Altschul(1982) regardmg the outcome of conhnumg professionaleducahon m the UK However, two UK studies haverepKJited that speafic contmumg educahon programmescan improve dmical prachce and enhance patient care(Bignell & Crotty 1988, Hughes 1990)

Bignell & Crotty (1988) have used a competency-basedevaluahon model to assess whether ENB Course 923(Developmg Nursmg Care) enhanced ability to improvepahent care The course members and their semor nursemanagers were mvited to p>arhapate m the queshonnairestudy 6 months after the complehon of the course, aresponse rate of 76% was achieved In the area of individu-alized care, improvement m effechveness and efficiencywas rated at 85 39% by course members and 97 49% bytheir managers Orgamzahon m dmicai work was alsoawarded bgh scores, 90 5% and 90% respechvely

From thar findmgs, Bignell & Crotty (1988) condudedthat contmumg professionai educahon can lead to anoverall increase m both the effechveness and effiaency ofqualified nurses to improve their chmcal prachce and theirability to enhance pahent care

Hughes' (1990) evaluahon of ENB Course 941 (Canngfor Older People) has revealed that eight course members(M = II) felt more confident m their abihty to contnbute topahent care Several identified instances m which they hadused their mcreased knowledge to improve patient care,although an identified area of concem was the difficulhesexpenenced m applymg this knowledge to dmical prac-hce One manager («=6) claimed that a course memberhad demonstrated the use of research findings in dinicalpractice as a direct response to speafic course contentHowever, thew studies are limited by their lack ofobserved performance data, thus the unpad of thecourses on the nurses' actual chnicai practice is notkiK)wn.

Maggs (1991) has asserted that the pnmary aim ofconhnumg professional education for nurses must be toimprove direct pahent care, and Hicken (1990) has arguedthat nurses have a duty to apply their professionalknowledge to dimcal prachce m a skilled, responsible andappropnate marmer Few surveys have analysed whatresources nurses perceive to be significant for developingtheir rationale for practice and the creahve and cnhcalthinking needed to apply knowledge m a sblled, responsibleand appropnate manner

One study in the USA has revealed that contmumgprofessional education can contnbute to nurses' percep-hons of their role, encourage nurses to reflect on practiceand change their rahonale for prachce (Warmuth 1987)This hterature search, however, has revealed no evaluativeUK-based studies that explore these issues

Research-based practice

There is considerable evidence to suggest that nurses aregenerally unaware of research findmgs on which dimcalprachce ought to be t)ased (Myco 1980, Bamett 1981,Wells 1983, Akmsanya 1988, O'Bnen & Heyman 1989)Myco (1980) has suggested that this may be partly due togeneral lade of commitment to the mdusion of researchmformation in the cumcula of contmumg professionaieducation programmes Akmsanya (1988) has arguedforably for all nursmg educahon to be research-onentatedso that changes to chmcal pradice can be dearly justifiedIn this he echoes the Bnggs Committee who, almost 2decades ago, pomted to

the need for research [tol become part of the mental equip-ment of every practismg nurse and nrudwife

(DHSS 1972)

While Hughes (1990) has reprarted that an maeased use ofreseardi m dmical prachce was an acknowledged outcomeof ENB Course 941, a shidy by Hunt (1987) has demon-strated that the acquisition of knowledge and an awarenessof research findings are not always reflected m dmicalprachce Similarly, Stanton & Crotty (1991) found thatattendance on the ENB Course 870 did not necessanlyenable the parhapants to implement research findmgs mtheir prachce

Hunt (1987) camed out research m one regional healthauthonty in England to mveshgate the processes used bynurses to translate research findings mto practice Everyeffort was made by the teadung staff and informahonservices to provide evidence for staff that current prachcefor mouth care and pre-operahve lasting was not the bestthat could be offered Hunt (1987), however, witnes^d

1136

Conttniung professtonal educatton

considerable resistance by ward staff to the proposedchanges m dimcal practice She conduded that it is toosimphshc to antiapate that acquinng new knowledgealone can change prachce, a pomt also made by Peden et al(1990) Warmuth (1987) has pomted out

While it IS impossible to uhhse knowledge that is notpossessed, it is quite possible to possess knowledge that is notutilised

Further research explonng the processes nurses use orperceive as important to the utilization of knowledge mdimcal practice is needed if the potential benefits ofcontinuing professionai education are to be maximized

Personal and professional development

Altschul (1982) has argued that the aim of conhnumgprofessional education should not only be to update nurseson the functional requirements of the job but also todevelop other skills This view is also supported by Tumer(1991) In a recent survey m the USA, he found that per-sonal satisfaction, the joy of leammg, mcreased knowledgeof new techmques and self-assurance were perceived bynurses to be the greatest benefits they had gained fromcontmumg nursing educahon

Bignell & Qotty (1987), working in the UK, havedeveloped a model for evaluating conhnumg professionaleducation which is underpinned by a theory that con-tinumg professional educahon programmes are compnsedof four mam components professional, educationai andindividual development, and the enhanced abihty toimprove nursing practice

While there are few empincal studies which addressthese issues, an excephon is Bignell & Crotty's (1988)evaiuahve work. Their study of ENB Course 923 foundthat course members not only reported an mcreased effec-hveness and elfiaency m their climcal practice and pahentcare but that the course had provided opportumties foreducahonal, personal and professional developmentMany course members identified an increased knowledgebase, an mcreased awareness for the need for furthereducahon and a greater interest m readmg artides

Several partiapants also identified other outcomes,including a greater awareness of professional issues,improved self-confidence, and a greater abihty to look cnh-cally at all aspects of their dimcal prachce These sameresearchers reported similar findings m their evaluahon ofan BNB Course 870 cohort (M = 10) However, they notedthat different grades of staff reported different outcomes atthe 6-mcmth follow-up interview (Stanton & Crotty I99I)

Career development and staff retention

Mackereth (1989) has argued that quahfied nurses havevery dear reasons for attendmg courses This was also afindmg of Rogers (1983a) whose questionnaire survey(n = 1908) revealed that 64% of the respondent nursesundertook a Joint Board of Chmcal Nursing Studies (nowreplaced by the National Boards) post-registration coursebecause they thought it would help in their promotionprospects

Rogers' (1983a) study found that career aspirahons werea sigmficant factor withm the deasion-makmg process,although a later study found no sigmficant difference inthe career aspirahons of qualified nurses (M = 8 I 4 2 ) andrespondents who had completed a Joint Board Certificatecourse (Rogers 1983b)

Studies in North Amenca have also identified that careeraspirahons of individual nurses are significant mohvationalfactors lnfluencmg participation m contmumg professionaieducahon (eg O'Connor 1979, Schoen 1979, Thomas1986)

Larcombe & Maggs (1991) have asserted the importanceof understandmg the significance of contmumg professionaieducation to career aspirations and pomt out that

The process of identifying and meetmg continuing pro-fessional education needs should take place witbn the contextof, and contnbute to, planned career development

lntnnsic to the PREPP proposals is that professionaidevelopment and contmumg professional educationshould take place withm a career development framework(Shuttleworth 1990) However, few empincal data existwhich clearly identify the contnbution made by attendanceat contmumg professionai education programmes to thecareer advancement and progress of mdividual nurses

Dodwell (1983a) has argued that, while the pnmary aimof contmumg professionai education is the improvement ofpatient care, it should also raise morale and mcrease jobsahsfaction Crotty (1987) has already pomted to thepotenhal relahonsbp between conhnumg nurse educationand the prevention of bum-out Indeed, Mackereth (1989)has suggested that, through research, the developmentof appropnate contmumg professional education pro-grammes supported by adequate resources could improvethe rates of staff retention in dimcal areas and perhapsattract back nurses who have left the service

Lathlean et al (1986) have evaluated post-registrationschemes m three health distncts for newly qualified nursesBy companng the future career plans of course members{n = 6) with non-course members (« = 6), they conduded

1137

K.L SamtaHetal

that conhniung professional educahon does have posihve

imphcations for staff retention

CONCLUSION

This hterature review reveals that there is a strongly held

assumphon that continuing professional education in

nursirtg has benefits for nurses, dients and the service It is

on this premise that the PREPP proposals are based A

strong theme throughout the hterature is concem that

many current contmumg professionai educahon events fail

to dehver anhapated improvements in reflective prachce,

research awareness and creative and cnhcal thinking

needed to improve pahent care

Paradoxically, the small number of research studies

undertaken have demonstrated that speafic continuing

professionai educahon programmes can enhance pro-

fessional education and personal development, staff

retenhon rates and pahent care, no studies reported

predominantly negahve findmgs The tendency not to

report programme failures imphes that the hterature does

not accurately reflect the effechveness and efficiency of all

continuing professional education events

A review of the hterature has also revealed that little is

known about the views of nurses and their percephons of

conhnumg professionai education This is a surpnsmg

omission m the light of the significance of the consumer

withm the learmng process Another notable gap in the

hterature is the comparahve absence of cost-benefit

analyses and other coshng data

The evidence suggests that the personal needs of nurses

are not being met, which has implicahons for the effiaency

and cost-effechveness of contmumg professional education

If the UKCC's proposed plans to introduce mandatory

conhnumg professionai education within a resource-

consaous environment is to have maximum benefits for

dients, nurses and the service, further empincally based

work IS mdicated

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