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INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES

Effectiveness of continuing education programmes in nursing: literature review Odette Griscti

MHSc RN

Assistant Professor, Joint Cape Breton University/St. Francis Xavier University Nursing Program, Cape Breton University, Sydney, Nova Scotia, Canada

John Jacono

PhD RN

Professor, Joint Cape Breton University/St. Francis Xavier University Nursing Program, Cape Breton University, Sydney, Nova Scotia, Canada

Accepted for publication 14 November 2005

Correspondence: Odette Griscti, Joint Cape Breton University/St. Francis Xavier University Nursing Program, Cape Breton University, PO Box 5300, 1250 Grand Lake Road, Sydney, Nova Scotia, Canada B1P 4S3. E-mail: [email protected] doi: 10.1111/j.1365-2648.2006.03940.x

G R I S C T I O . & J A C O N O J . ( 2 0 0 6 ) Journal of Advanced Nursing 55(4), 449–456 Effectiveness of continuing education programmes in nursing: literature review Aim. The aim of this paper is to review the literature on what facilitates or inhibits continuing education in nursing and to identify ways to make continuing education more effective. Background. Healthcare professionals have always been encouraged to update their knowledge and maintain clinical competence. The rapid changes currently taking place within healthcare systems have increased the pressure from direct care providers, professional bodies and the general public for nurses to engage in continuing education programmes. Despite a growing body of empirical research on this topic, the effectiveness and impact of continuing education remains underexplored. Method. A literature search was conducted in January 2005 using CINAHL, Medline, the Cochrane databases and the Internet. Keywords used were: ‘continuing education’, ‘professional development’, ‘viability of continuing education/professional development programmes’, ‘evaluation of continuing education/professional development programmes’ and ‘effectiveness of continuing education/professional development programmes’. No date restrictions were imposed. Results. Factors that facilitate the implementation of continuing education in nursing arise from individual, professional and organizational perspectives. While the philosophy behind continuing education is to encourage nurses to become lifelong learners, the learning method chosen for such programmes is often didactic in nature, as opposed to encouraging nurses to take initiative and direct their own learning. Continuing education is intended to ensure healthcare practitioners’ knowledge is current, but it is difficult to determine if those who attend these courses are implementing what they have learnt. Conclusion. To make continuing education programmes more effective, nurses need to have a more participatory role in their learning. A concerted effort should be made to make continuing education attainable and realistic.

Keywords: continuing education, effectiveness, evaluation, literature review, nursing, professional development

2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd

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O. Griscti and J. Jacono

Introduction The importance of continuing education has been increasingly debated in nursing literature over the past few years. It is of international concern to policymakers and stakeholders in the healthcare sector and is reflected in various statutes, such as the Nurse, Midwives and Health Visitors Act (1979) and recommendations of the National Staff Committee for Nurses and Midwives (1981) in the United Kingdom (UK), the Pew Health Profession Commission Reports (1995, 1998 in the United States (US), and the National Nursing Competency Project (1997) and Canadian Nurses Association Policy Statement (1998) in Canada. Yet, despite the obvious importance of continuing education to the nursing profession, and the extensive involvement of various stakeholders, little is known about whether continuing education works in practice. A literature review was therefore undertaken to examine discussion papers and studies on continuing education and the factors that affect its value in nursing.

Search methods A computerized search up to January 2005 was conducted using CINAHL, Medline, the Cochrane databases and the Internet. This was followed by a literature search of relevant references in the studies included. The keywords used in the search included ‘continuing education’, ‘professional development’, ‘viability of continuing education/professional development programmes’, ‘evaluation of continuing education/ professional development programmes’ and ‘effectiveness of continuing education/professional development programmes’. Articles meeting the following criteria were retained for further analysis: (a) articles/studies whose main content was specific to continuing education as opposed to formal education; (b) articles/studies whose content was specific to viability/effectiveness/evaluation of continuing education in healthcare disciplines; (c) articles/studies which were peer reviewed, as opposed to anecdotal literature; and (d) articles/ studies which were published in an English language journal. This literature review will focus on the potential impact of continuing education on nursing competence and on lifelong learning. It will not include literature on philosophy in nurse education, adult learning principles or specific curricular approaches to adult learning.

Results A total of 40 articles met the selection criteria and were used in the review. Most of the articles/studies were conducted by researchers in nursing and ancillary healthcare disciplines in 450

the UK, US and Canada. The geographical and disciplinary distribution of these studies suggests that continuing education is a matter of widespread concern. The scope of these studies conveniently enables comparison of similarities and differences between professions and countries. However, the research has tended to be somewhat fragmented and fails to provide a unified picture in terms of the effectiveness of continuing education from a practical point of view. Most of the studies reviewed, tended to be restricted to evaluation of isolated continuing education programmes. The literature also revealed a lack of needs analyses underpinning continuing education programmes and a failure to evaluate outcomes of programmes taking into account clients’ views and experience or health professionals’ performance. Moreover, none of the studies reviewed were followed up or validated through replication. Hence, it may be argued that while most of the research on continuing education is appropriate for individual programmes, on a universal level it is rather patchy and has limited generalizability. This review attempts to discuss whether the broad aims of continuing education are being met, as well as to identify the gaps in research that need to be addressed to make continuing education more effective by ensuring that nurses are safe and competent to practice.

Continuing education methods Both the English National Board (ENB) for Nursing, Midwifery and Health Visiting (1990) and American Nurses Association (ANA) (1994) define continuing education as any postbasic nursing education aimed at actively engaging nurses in a lifelong process of learning, with the ultimate goal of improving delivery of health care. They assert that the intent behind continuing education is to help nurses take the initiative and cultivate an aptitude for lifelong learning. Continuing education in nursing is necessary because of an unprecedented growth in professional knowledge, rapid changes in the healthcare system and the consequent changes in nurses’ roles (Glazer 1999, Lundgren & Houseman 2002, Brunt 2003). Health practitioners need to adapt as professional requirements change to maintain competence and to safeguard the public. However, while there is some agreement about the aim of continuing education, there appears to be no consensus in the literature reviewed on what constitutes continuing education (Barriball et al. 1992, Lawton & Wimpenny 2003). Some authors focus only on structured and planned activity and prefer to treat any self-directed learning as a separate entity (Lawton & Wimpenny 2003). In contrast, other authors adopt a more inclusive approach to continuing education. They claim that it is more than structured study days and


Integrative literature reviews and meta-analyses

courses and should be an all-encompassing term that covers any self-directed initiative that nurses might take (Furze & Pearcey 1999, Brunt 2003). The majority of studies on continuing education tend to be focused on structured and planned programmes (Nielson & Miaskowski 1987, Gill & Ursic 1994, McLeod et al. 1994, Timms & Ford 1995, Jordan 1998, Jordan et al. 1999, Bullock et al. 2002) as opposed to self-directed learning. While studies of formal methods of instruction have significant value in the evaluation of continuing education programmes, more research studies are needed that address informal methods of learning currently used by nurses, such as journal readings, experiential learning and other initiatives. Such investigation is essential, particularly if we accept (with the ENB and ANA) that one of the drivers behind continuing education is to encourage nurses to take the initiative and be responsible for their own learning. Determining an appropriate learning process is key to implementing continuing education successfully in nursing, but it is equally important to measure if continuing education programmes or self-directed learning have achieved their goal (Furze & Pearcey 1999, Jordan 2000). The lack of follow-up evaluation means that there is little evidence to show that continuing education improves patient outcomes (Barriball et al. 1992, Furze & Pearcey 1999, Jordan 2000, Eustace 2001) or that acquired, theoretical knowledge is applied in practice. Barriball et al. (1992) noted that continuing education tends to focus on cognitive aspects of nursing practice and fails to deliver improvement in creative and critical thinking, research awareness and reflective practice skills. Barriball et al. (1992) argued that these skills are crucial if the knowledge gained through continuing education programmes is to be transferred to practice. This view is echoed by Lundgren and Houseman (2002) who noted that continuing education is too focused on the technical side and does not address factors that reflect aptitude and interpersonal skills – qualities that Diers (1985, p.54) described as necessary to ‘humanize institutions’. These observations are not new. Over 20 years ago, Scho¨n (1983) remarked that professional education tended to follow a positivist cultural paradigm in which the greatest importance is attached to acquisition of knowledge, rather than aesthetics or its application to practice. Nevertheless, integration of aesthetics, to help nurses to focus more on the humane and creative aspects of care does not happen by the mere inclusion of such topics in the curricula; it needs to be planned and requires an appropriate style of teaching that involves direct participation by the audience (Scho¨n 1983). Although continuing education remains largely didactic at present, the importance of moving to a participatory para-

Effectiveness of continuing education programmes in nursing

digm has been noted in a systematic review by O’Brien et al. (2003). This review considered the effects of educational meetings, such as lectures, workshops and courses, on professional practice and healthcare outcomes. Results indicated that interactive workshops, rather than lectures and academic instruction, were the best way to influence changes in professional practice.

Identifying needs While continuing education needs to become more student centred, it is equally important to identify other stakeholders and their needs (Lawton & Wimpenny 2003). As well as individual practitioners, these include employers and professional bodies. With regard to individual practitioners, some nurses may only participate in continuing education programmes to meet the requirements of the statutory bodies which periodically revalidate nurses’ right to practice (Grossman 1998, Lawton & Wimpenny 2003). However, a number of studies indicate that nurses also participate in continuing education out of a desire to further their knowledge. This finding appears common across countries, being reported in studies conducted in both the UK (Lindsay 1990, Larcombe & Maggs 1991, Turner 1991, Thurston 1992) and US (O’Connor 1992, Waddell 1993). O’Connor (1992) asked nurses to indicate their reasons for participating in continuing education. Respondents identified seven motivational factors, with improving professional knowledge and skills rated the highest. Turner (1991) reported that nurses cited personal satisfaction, joy of learning, increased knowledge of new techniques and self-assurance as benefits gained from continuing education. In a meta-analysis of 22 studies on why nurses participate in continuing education, Waddell (1993) indicated that motivational orientation was the major reason nurses participated in continuing education programmes. Although external pressures such as recertification, relicensure and employer expectations featured highly in this study, they were marginally surpassed by cognitive interest, i.e. learning for its own sake. All these studies suggest that nurses have a strong interest in continuing education. However, as Waddell (1993) remarks most studies were limited to nurses who had participated in continuing education programmes. Studies including nurses with no known history of participation in continuing education programmes might yield different findings, thus providing a more complex picture. It argued that the driving force behind continuing education goes beyond satisfying individual needs (Grossman 1998). There is increasing pressure from the public, who


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are pushing health authorities to ensure that health professionals are safe practitioners. In turn, the concerns of employers and professional bodies have provided an impetus to use regulatory action as a means to ensure currency of knowledge and competence in practice (Grossman 1998, Eustace 2001, Glazer 1999). However, employers and professional bodies have different reasons for requiring healthcare professionals to remain competent. Healthcare authorities are mainly concerned with the costs of providing high quality care and protecting themselves against potential litigation (Brunt 2003). Professional bodies’ interests are to advance professional development, to ensure autonomy and to preserve self-regulation (Grossman 1998). In addition, it appears that while professional bodies may be more interested in advancing the profession’s body of knowledge through their members’ lifelong learning and research, healthcare authorities may be more focused on addressing immediate and short-term needs such as orientation programmes, in-service training and acquisition of new skills, rather than lifelong learning (Lawton & Wimpenny 2003). These differing mandates may lead to tensions when it comes to planning for continuing education programmes, even though the goals of both are ultimately similar: to protect the public from malpractice by ensuring safe, competent client care (Grossman 1998, Lawton & Wimpenny 2003). The differing mandates of healthcare authorities and professional bodies may also explain why, in many countries, continuing education programmes tend to be provided by two separate entities: the hospital/organization that employs the nurse and the national/provincial nursing statutory body that regulates professional practice. In the meantime, nurses are caught in the middle, undertaking (and often financing) continuing education courses, but not involved in their evolution (Nolan et al. 1995). Marginalization of nurses may further occur when, as Glazer (1999) argues, politics influence the direction which continuing education needs to take. There are times, Glazer (1999) argues, when what is ideal has to be sacrificed to political and practical realities. Thus, if the public is pushing organizations or professionals to address certain issues, nurses may feel obliged to comply with organizational or professional demands rather than pursue their own needs. Ultimately, the success of continuing education policies and programmes can be greatly enhanced by including all stakeholders in discussions prior to implementation (Grossman 1998). However, the literature critiqued in this review suggests that, in fact, most continuing education programmes are based on the needs of single stakeholder groups, and rarely on a consensus of all interested groups. A needs assessment of all parties involved becomes particularly 452

crucial if continuing education is to be imposed as a mandatory requirement.

Mandatory vs. voluntary participation The issue of mandatory continuing education in nursing is a contentious one. An increasing number of policy directives advocate mandatory participation in continuing education programmes (Eustace 2001, Brunt 2003). This policy suggestion arises, in part, out of concern that voluntary participation in continuing education might result in a lack of commitment by some nurses (Lundgren & Houseman 2002). Carpenito (1991) suggests that while the majority of people in a professional group are interested in advancing their education, as in any other profession, there are a number of ‘laggards’ who do not show any interest at all. It is this group of laggards that Carpenito (1991) suggests should be the focus of continuing education policies. Such policies should encourage this group to give up their isolation and move toward lifelong learning. Similar sentiments were expressed in a 1980 study carried out in one US state by Puetz, which found that those nurses who sought opportunities to attend continuing education programmes were likely to be motivated, competent nurses. Therefore, Puetz (1980) asserts, since the typical non-attendees at continuing education programmes are probably the ones who need updating most, justification for mandatory education may be warranted. However, it cannot be assumed that those not attending continuing education programmes are either not motivated or not competent practitioners. According to Lundgren and Houseman (2002), one of the pitfalls of targeting high-risk groups only, is that such an action would only ensure minimal standards of practice and would not help to improve current practice. If the scope of continuing education is only to eliminate substandard performance, other mechanisms, such as disciplinary boards, are already in place to address this. Grossman (1998) adds a further dimension to this argument by asserting that it is better if disciplinary action, such as decertifying or revoking a license, is implemented for failure to provide ongoing quality care, rather than for belated ethical or clinical malpractice. Whilst prevention is invariably better than cure, the institution of punitive measures to encourage professional development is of questionable value. Senge (1990) argued for a learning organization in which employees perceive continuing education as part of their job, instead of as a means to avoid punishment. As Barriball et al. (1992) suggested, it is the learner’s inherent motivation to learn that plays a pivotal part in knowledge acquisition. Mere attendance at continuing education programmes does not guarantee



knowledge acquisition. One tentative solution to this dilemma is to identify what would motivate disinterested nurses to learn and then address this.

Evaluating competence Once the core needs relating to continuing education have been identified, it is essential to evaluate if continuing education programmes meet the desired outcomes. Barriball et al. (1992) concluded that there was little information on how to evaluate outcomes of continuing education programmes. As they suggest, this is as a surprising omission in the literature, particularly in view of the aspiration of health authorities to provide continuing quality care in the face of rapid changes. An appropriate system is necessary to evaluate whether health professionals are building their capacity for selfdirected learning and, as a result, becoming more competent in their practice. Different strategies have been adopted internationally to ascertain whether nurses are taking the initiative. In the US, nurses need to provide evidence of attendance at board-certified events, while in the UK and Canada random audits of personal professional profiles take place (Canadian Nurses Association 1997, Furze & Pearcey 1999). The fact that evaluation strategies may vary between countries is not necessarily concerning. Both evaluation methods can be effective; however, both have their pitfalls. Grossman (1998) contended that annual presentation of certifications, as in the US, does not guarantee that learning has taken place nor does it establish relevance to practitioners’ specific work. On the other hand, while personal profiles, as in Canada and UK, may stimulate nurses to reflect on their practice, Furze and Pearcey (1999) argue that the number of audits carried out by the licensing body in any particular year is likely to leave a majority of nurses’ profiles unexamined. In addition, none of the strategies examined above assess for non-technical aspects of care or the application of theory in practice by the practitioner. Nevertheless, some professions attempt a more holistic approach to assessing professional knowledge and competence. For instance, several Canadian provinces require physicians to undergo periodic peer review of their practice (Lundgren & Houseman 2002). This method is not problem-free, as the ability to make an objective evaluation is affected by the fact that the review is performed by colleagues. In short, no system is perfect, and finding an evaluative process that is reliable, valid and efficient, remains a goal (Grossman 1998). Furthermore, as Grossman (1998) argues, it is not possible to test every aspect of competence in a profession; there are so many potential aspects, but only the

Effectiveness of continuing education programmes in nursing

core elements can be measured. However, measuring these core elements for everyone, on an ongoing basis, may help to establish uniform standards in a particular area and help establish a baseline that can be used to predict future needs based on performance. In a rapidly evolving environment, such as health care, what constitutes sufficient time spent on continuing education is also important. Requirements vary between countries. Currently, the Nursing and Midwifery Council (2004) mandates that nurses undertake 35 hours every 3 years. US requirements vary between states, ranging from a low of 5 hours per year to a high of 45 hours in 3 years (Brunt 2003). These figures suggest that there is a wide disparity in the number of continuing education hours required between and within countries. A possible explanation for this disparity is that continuing education determinants are affected by a variety of local needs and perceptions, such as what constitute satisfactory patient-care outcomes. Of more immediate concern is the fact that, in the literature reviewed, there was no evidence presented about tools used to measure how the effectiveness or frequency of continuing education is determined.

Evaluating outcomes and impact One way to determine how much time practitioners should spend on continuing education programmes is to obtain some form of measure that indicates when the goal of continuing education has been achieved. Continuing education is intended to enable nurses to pursue their professional development and to fulfil the demands of their role safely and competently. However, few empirical studies show how continuing education actually affects practice in the UK (Barriball et al. 1992, Furze & Pearcey 1999, Jordan 2000) or in the US (Eustace 2001). Most of these studies rely solely on the health professionals’ perceptions of change, which does not necessarily equate to improvement in patient care. Theoretically, an appropriate way to evaluate any change in behavioural patterns is through observational studies. Jordan (2000) identified five observational studies that were being undertaken in nursing. However, as Jordan points out, the practical, ethical and budgetary difficulties in carrying out such studies, as well as an increased risk of the Hawthorne effect, are potential pitfalls of this method of enquiry. Another possible approach to evaluating patient outcomes is through patient surveys. Once more, there appears to be a dearth of research using this method. In their literature review, Furze and Pearcey (1999) commented that there were no UK and only two US studies that used this method. However, both Furze and Pearcey (1999) and Grossman


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What is already known about this topic • In view of advances in the healthcare field, it is crucial that nurses update their knowledge. • Continuing education programmes are expensive. • There is a paucity of studies about whether these programmes improve client outcomes and if they are worth the investment.

What this paper adds • Gaps in the literature from nursing research that need to be addressed in relation to continuing education and lifelong learning include why some nurses choose not to involve themselves in continuing education programmes and what might best entice such nurses to take the initiative and responsibility for their own learning. • Healthcare providers, professional bodies and nurses can work together to make continuing education programmes accessible and sustainable by all becoming involved from the initial stages of planning continuing education programmes until their evaluation. • The effectiveness of continuing education on client outcomes should be evaluated by more objective outcome measurements, through monitoring of clients’ records and evaluating outcomes against best-practice benchmarks.

(1998) advocate caution in the use of patient surveys as, despite assurances of anonymity, patients may fear being identified, and therefore make what they consider to be desirable, rather than truthful, responses. Perhaps a less obtrusive and more objective way of collecting data to evaluate the effectiveness of client outcomes is monitoring of client records and noting any improvement in care. However, as patient outcomes are influenced by care received from a variety of sources, a way needs to be found to focus specifically on nursing outcomes. The Registered Nurses Association of Ontario Project (1999), which provides a list of best nursing practice guidelines for client care, may act as a benchmark to identify, measure and evaluate nursing outcomes.

Conclusion From the literature reviewed it appears that continuing education has attracted considerable attention in the nursing profession. However, it is also evident that research into the topic has been restricted to evaluation of isolated structured 454

continuing education programmes that were not validated through replication. Whilst this may seem to present a fragmented picture of whether or not continuing education programmes work in practice, nevertheless it does demonstrate an increasing awareness, as well as initiatives, to keep nurses’ knowledge and skills up to date. Direct-care personnel shortages and pervasive underfunding have conspired to make life-long learning a difficult undertaking in nursing and related disciplines. In spite of this, the growing numbers of diploma-trained nurses who go on to obtain a degree, and the increasing number of new, university-trained nurses, suggest that a thirst for knowledge, and thus quality healthcare delivery, continue to exist in the nursing profession. The goal now should be to keep that motivation alive. In this sense, educators have a pivotal role to play. Educators can help to sustain this enthusiasm in nurses who want to learn, and also stimulate similar eagerness in less-motivated nurses, simply by involving learners more. It was noted in the literature reviewed that participatory workshops seem to enthuse nurses more than didactic lectures; this suggests the need for more student-centred approaches when planning continuing education programmes. Likewise, continuing education can be exciting if educators make learning experiences diverse and appealing. Educators should take time to assess learning styles and adopt different learning strategies, when planning or executing continuing education programmes in order to take account of different learning needs. Similarly, organizations should adopt a more participatory approach to address continuing education in nursing. From this literature review, there appears to be a rift between the needs and desires of various stakeholders in health care and nurses. Organizations and professional bodies need to be more aware of what nurses want to learn, as well as to understand factors such as poor working conditions, understaffing and family commitments which may hinder some nurses from pursuing further education. It is encouraging that all sides in the healthcare system recognize the value of continuing education for nurses; however, more needs to be done to bring all sides together to identify the learning needs of all parties and overcome differences. Hence, health authorities and professional bodies should demonstrate a commitment to involving nurses in the organization process from the initial stages of planning continuing education programmes, to the evaluation of organized learning experiences. The review also identified a series of gaps in empirical studies around continuing education issues. More studies are needed on why some nurses are disinterested in pursuing



continuing education. It is, after all, these nurses who need to be most mindful of their competence and who have the greatest need to develop a capacity for lifelong learning. Finally, an evaluation process should be developed to determine if continuing education is achieving its desired outcome: namely, improved client care. Other mechanisms exist, such as clinical reflective practice sessions, clinical mentoring and clinical evaluations, any or all of which may be just as effective in ensuring public safety and keeping healthcare professionals competent and interested in their professional development. If continuing education is not achieving its goal of ensuring that healthcare professionals are competent and safe to practice, it is important to implement alternative measures which will promote knowledge acquisition and continued competency in a constantly changing environment.

Acknowledgement The authors would like to thank Mr Tom Ayers for his input on article revision.

Author contributions OG and JJ were responsible for the study conception and design and drafting of the manuscript. OG performed the data collection and data analysis. OG and JJ provided administrative support. OG and JJ made critical revisions to the paper. JJ supervised the study.

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