Background of the Study
Professional development needs are challenged by multifarious reasons that place barriers to their fulfillment. The World Health Organization World Health Report (WHO, 2000) states that human resources are the most important of the health system’s resource inputs. The performance of health care systems ultimately depends on the knowledge, skills and motivation of the people responsible for delivering services. Education and training are key investment tools as old skills become obsolete with the advent of new technologies (Richards, 2008). This is in line with strategic planning of World Health reports, which places emphasis on the need for continuing care providers. Nurses are required to be competent practitioners, have scientific base for education for health practice, be knowledgeable to communicate with increasingly informed patients/family members and have a mastery of technology in the dynamic arena of patient care and condition. As an example, where education and training for junior nurses functions poorly, or where senior staff lack adequate time and resources to update their knowledge and skills, future shortfalls can be expected. The Nursing Professional Development Scope and Standard of practice,(NPDSSP) defined Continuing education (CE), or Continuing Professional Development(CPD) as “systematic professional learning experience designed to augment the knowledge, skills, and attributes of nurses that enrich their contribution to quality health care and pursuit of professional goals(NPDSSP,2010). Similarly, the American Nursing Credentialing Center (ANCC) posits that continuing nursing education are those experiences intended to build upon the educational and experiential bases of the professional registered nurse (RN) for the advancement of practice, education and administration in conjunction with research or theoretical development with a view to improving the health of the public and registered nurse pursuit of professional career goals (ANCC, 2011).
The importance of continuing education and its relationship to professional development, licensing and re-licensing cannot be overemphasized. A programme of continuing professional development can be viewed as having a range of functions, namely: the maintenance role that fosters the notions of life-long learning; the survival role that requires practitioners to demonstrate their ongoing competence; and the mobility role that aims to increase a person’s employability. In the health care arena, scientific and technological advances lead to obsolescence of knowledge and professional skill in remarkably short time. Among the significant changes are shifts in population demography, particularly the increase in the aging population; cultural diversity of the population; changing patterns of disease; increased technology; increased consumer expectations; the high costs of health care; the changes in health care financing as well as other health care reforms. These changes have led to institutional restructuring, staff downsizing, increased quality care, decreased lengths of hospital stay and more care being provided in the community and in homes. These changes coupled with changes in nursing practice create demand on nurses to undertake continuing education programmes to remain competent and relevant (Deloughery, 1999). Inferably, comprehensive basic professional preparation is no longer sufficient for a whole life of practice; and given the emphasis on evidence-based practice, nurses need to continuously update their knowledge and professional abilities. In view of these imperatives, continuing education has increasingly become essential to guarantee high quality nursing practice (Schweitzer & Krassa, 2010).
Furthermore, the changing health care delivery system has noticeable impact on nursing care delivery models. Nurses in advanced countries have assumed such expanded roles as independent nurse practitioners in many areas. These new roles are pointers to how nursing will continue to evolve in the health care system in many countries. Such changes are having dramatic influences on where nurses practice with an increasing trend to provide health care in hospitals, home settings, communities here in Nigeria and be able to fit into the system in the developed countries like America and United Kingdom (Olade, 2005). This situation is a challenge to the present Nigerian Nurse, which needs to be met. The trends require polyvalent nurses knowledgeable in most if not all aspects of human life, to enable her render evidence based services to the individuals and the society as a whole. To meet these emerging needs, the profession needs to re-evaluate not only the curricula for new graduates but also that of maintenance of competence in nursing practice. It is therefore necessary that Nurses undergo continuing education in form of workshops, seminars, conferences, symposia, and above all undertake nursing education at university level to meet up with professional responsibilities to the society. Continuing education program of the nurse at the university level exposes her to related courses such as Humanities, Medical Sociology, Law, Public Relations, Health Economics, Health (Nursing) Informatics, Psychology, and a host of other Nursing Science courses. These courses will help the graduate nurses to relate with other health care professionals from other disciplines. The knowledge of personality traits through psychology and effect of culture and belief on health will enhance the effective implementation of the Nursing Service. Nurses with this level of education have been linked to improved patient outcomes and delivery of more cost effective/ quality care (WHO, 2000).
In addition, evidence revealed that expanding the amount of care provided by University (BSN) prepared Nurses on hospital units to 80% would result in significantly lowered re-admission rates, reduced medical errors, shorten length of patients stay on admission in the hospital. These outcomes translate with cost savings that would more than offset expenses for increasing the number of BSN educated nurses in hospital settings. Higher education and advanced degrees adequately prepare registered nurses (RNs) to develop process improvements, which address medical errors, acquire more knowledge and skill and be more assertive and confident in their practice (Institute of medicine (IOM), 2010). Continuing education enhances previous learning and enables learners to keep up with contemporary changes. To be effective, continuing education should be designed with the course content based upon closing gap- needs of target learners. Course content areas should be appropriate as judged by expert viewers; the instructor must be adequately prepared to teach content based upon educational and clinical experience; also the expected change in behavior/ competency based upon the learner participation must be specified (American Association of Colleges of Nursing[AACN],2012).
Florence Nightingale (1859) all through her “Notes on Nursing” advocated that nurses must learn constantly not only through observation and experience but also seek new knowledge and evidence through continued learning. Similarly, like the pilot who must always keep abreast with advances in his field for safety of his passengers, nurses must engage in continuing Education all through their career life for evidence based, safe and high quality care to be rendered to patients with positive patient outcomes.
Participation in relevant /effective continuing education programmes in nursing have been credited with the ability to enhance the quality of nursing care by improving the knowledge base of staff with the consequence of raising standards and producing a more cost-effective service; and serve as bedrock for career opportunities such as promotion and self actualization. However, certain barriers could block learners from having a chance at these privileged opportunities. These barriers could be situational, institutional or dispositional in nature. Physical/Situational barriers include lack of time due to work, family and child care responsibilities; difficulties in paying course fees and fear of losing benefits, among others. Structural/Institutional barriers stem from difficulties related to the institution that provides the education, such as the school being geographically far/limited opportunities for learning near to place of residence, lack of transport; classes being held at inconvenient times, stringent admission requirements; lack of knowledge about learning opportunities and the school lacking student services. Institutional barrier relates to the extent the potential learner knows about the educational program. In the case of graduate nursing education, an institutional barrier could also stem from a misunderstanding of the role of a master’s degree in nursing and the opportunities this qualification provides for the individuals career trajectory. Lastly, attitudinal/dispositional barriers which refer to being nervous about going back to the classroom and concern about not being able to meet up; skepticism about the value of continuing education; low self-esteem and lack of confidence both generally and in relation to learning; low aspirations and lack of role models; lack of trust in formal institutions; and a perception that they are too old to learn. (Leading learning and skills [LSC], 2005).
According to Cross (1981), participation in a learning activity, whether in organized classes or self-directed, is not a single act but the result of a chain of responses, each based on an evaluation of the position of the individual in his or her environment. The motivation to participate in adult learning activities is influenced by the strength of factors that support participation versus the strength of factors that deter from participation. These factors are interrelated; however, for there to be a change the driving forces (the motivators) must out way the restraining factors.
Perceptions and attitudes are also major contributors to the variables that hinder participation in advanced education of Registered Nurses. Her attitude, perceptions, and self-evaluation about these factors positively or negatively determine whether she will seek for opportunities to engage or participate in continuing education (Cross, 1981).
If as shown by current research that continuing education contributes to the quality of nursing care/professional growth, the reasons that influence professional non-participation become more significant for the nursing profession. Hence, the researcher decided to undertake this study to investigate those factors nurses perceive as deterrents to participation in continuing education, especially at the university level.
Statement of the Problem
The need for nurses to adapt to the ever-changing health care environment require no further emphasis. Professional development plays an important role in the relevancy of the nursing profession because of the rapid and continuing progress in the medical sciences and ancillary vocations. Competency beyond graduation require that nurses recognize their limitations and seek training and re-training to update their knowledge, attitudes and skills with a view to remaining relevant within the confines of current research and developmental praxis in patient care. The nursing profession is accountable to society for providing high-quality care for patients and families. Post registration education further seeks to equip practitioners with additional and more specialist skills necessary to meet the special needs of patients and clients” (Abruzzese, 1996). Burns and Grove (1999) in their contribution emphasized that beyond basic nursing education, nurses need robust scientific knowledge to enhance and improve their decision-making skills regarding what care to initiate and how best to implement that care.
Regrettably, the nexus between CE and improved professional development/excellence in practice appears lost to some nursing practitioners. Their perceptions about CE/university based nursing programs may affect their decisions on furthering their education with a view to improving their knowledge and skills for better practice. To a large extent, many pay lip service to post-basic education based on the assumptions that nursing being a practical profession does not require extensive theories nor advanced education to be effective in practice and to implement the physician instructions; serve bedpan or administer medication to her patients.
The researcher, with many years cognate working experience as clinician cum CE coordinator, through interactions with some post registration course students from different health institutions in the country, observed widespread anti- intellectual bias towards intellectual advancement. Many in a nutshell, advanced defense mechanism postures to cover up their angst “managers and colleagues do not support us who are studying”; “work stress is making me miserable”; “I cannot manage the study and practice workload and dedicate quality time to my family” in conjunction with constant complaints about shortage of staff”. On a scale of balance, it does appear that a proportion of the students do not enjoy favorable support of their employers, managers and colleagues towards their post registration formal education programmes. Indicative of this lack of support are reports of being stripped of unit responsibilities they had before embarking on a programme of study; being excluded from ward level decision making because they are students; being overlooked for senior posts/denial of promotions despite the edge of undertaking study programmes relevant to promotion of enhanced patient care ; and difficulty in obtaining cooperation from the unit manager and colleagues to complete projects such as problem solving in the work place which require a team effort. A proportion of students do not complete their studies. Reasons given have included the inability to meet deadlines set by the tertiary institution; work stress, which impacts on the time available to attend to studies; and family commitments.
Furthermore, it was observed that manifest interest in “the pursuit/engagement in undergraduate nursing education/ advanced nursing education programs attracted negative perception of coworker nurses and complaints of management reluctance to release the nurses seeking to undertake one form of CE or another. The BSc. Nursing part time program did not receive wide acceptance, hence, majority of nurses enrolled in such programs chose not to disclose their involvement with peers for fear of negative stigmatization, thus, described as secret study. Kazeem, (2008) inferably, averred that majority of nurses who possess positive attitude/yearnings towards learning (CNE) face enormous hydra-headed/multifarious challenges. In addition, promotions and career advancements in clinical practice are not contingent on the level of educational attainment but primarily based on years of practice and seniority. For instance many nurses whose highest level of education was diploma were in leadership positions within their workplace and in clinical teaching positions. Majority of nurses averred that they had witnessed many nurses in their workplace progress into leadership positions without university degree; and confirmed that potential nurse leaders were often selected by management and “groomed” for positions often difficult to fill (i.e., the employer provides support to prepare a nurse that shows potential and interest in leadership for the role, but enrolment in a graduate nursing education is not seen as part of this). Chitty ( 2005) stated that baccalaureate nursing students take twice as long to complete their school and enter work force, thus causing constraints of supply of nurses. Also worthy of note is that Mikanowicz (2004) had earlier postulated that nurses should stick to the basics and not mimic doctors to become nurse consultants and clinical practitioners. These and other mundane considerations amplify the notion whether graduate studies are worth the effort when career advancement was possible either way. This and other negative assaults on Nursing educational trajectory explained the reasons why most university graduate nurses slipped their certificates under lock and key, ostensibly to avoid public odium and ridicule. In contradiction from the above nuanced contributions, Richards (2008) wisely cautioned that performance of healthcare systems depends on knowledge and skills of people responsible for service delivery. It is recognised that higher-level/quality competencies and professional expertise result in part from years of clinical experience, however, this experience, is expected to be underpinned by advanced learning beyond initial registration as a nurse. Olashehinde Williams (2003) succinctly argued that part time program in Nigerian universities enable individuals on full time employment/jobs to develop their knowledge base. Practicing nurses need the support of their employers to enable them access continuing education in a continuous pragmatic schedule.
The lack luster attitude of Nigerian authorities towards all ramifications of Medicare is deplorable; we need a paradigm shift towards positive transnational ethos of public service. Surprisingly, these observations and lots more have not been empirically generated and documented but abound in most public and private hospital establishments in the country; they need to be investigated without hindrance and expeditiously addressed for avoidable setbacks in the wheel of progressive nursing care.
The foregoing comments/ observations aroused/sparked the researcher’s interest and formed the background upon which this study was conducted to among several others articulate reasons/find answers to the following questions: How do registered nurses view continuing formal education in the contemporary age? What are the barriers experienced by registered nurses with regard to continuing formal education, especially from the point of view of individual registered nurses in both public and private hospital establishments in Nigeria?
Purpose of the Study
To investigate the constraining factors to continuing education among nurses in three selected hospitals in Enugu State.
Objectives of the Study
Specifically, the objectives are to:
- Identify the personal factors hindering nurses from participating in continuing education.
- Ascertain the economic factors/challenges preventing nurses’ participation in continuing education.
- Identify the institutional/environmental factors that hinder nurses’ participation in continuing education.
- Determine the administrative factors that hinder nurses’ participation in continuing education.
- Determine which group of factors that have more constraining influence on nurses’ participation in continuing nursing education.
- Determine nurses’ perceived value of participation in continuing education.
- Identify nurses’ perceived personal motivations to continuing education.
- Determine nurses perceived benefits of participation in continuing education
- Determine nurses’ opinion on how to check the hindrances to participation in continuing education.
In pursuance of the set objectives of the study, the following research questions were posed:
- What are the personal factors constraining nurses from participating in continuing education?
- What economic factors discourage nurses from participating in continuing education?
- What are the institutional/environmental factors restraining nurses from participating in continuing education?
- What administrative factors restrain nurses from continuing nursing education?
- What group of factors has more constraining influence on continuing nursing education?
- What are the perceived values of continuing education among nurses?
- What are the perceived personal motivations for continuing nursing education among nurses?
- What are the perceived benefits of continuing education among nurses?
- What are the perceived views on how to overcome these hindrances?
HO1: There is no significant statistical difference between the personal factors hindering continuing education among nurses in the three selected hospitals.
HO2: There is no significant statistical difference between the economic factors preventing registered nurses participation in continuing education in the three hospitals.
HO3: There is no significant statistical difference in the administrative factors restraining registered nurses participation in continuing education in the three hospitals.
HO4: There is no significant statistical difference in the environmental/institutional factors hindering continuing nursing education among nurses in the three hospitals.
HO5: There will be no significant difference in the group of factors hindering continuing education among nurses in the three hospitals.
HO6: There is no significant statistical difference in the perceived value of continuing education among nurses in the three hospitals.
HO7: There is no significant statistical difference in the perceived personal motivations for continuing education among nurses in the three hospitals.
HO8: There is no significant statistical difference in the perceived benefits of continuing education among nurses in the three hospitals.