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Exploring ward nurses' perceptions of continuing education in clinical settings
Nurse Education Today 34 (2014) 655–660
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Exploring ward nurses' perceptions of continuing education in clinical settings Melissa Govranos a,1, Jennifer M. Newton b,⁎ a b
Nursing and Midwifery Education and Strategy, Monash Health, 246 Clayton Rd, Clayton, Victoria 3168, Australia School of Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Bldg 13 C, Clayton Campus, Australia
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Article history: Accepted 2 July 2013 Keywords: Continuing education Professional development Nurse education Staff development Work-based learning
s u m m a r y Background: Health care systems demand that nurses are flexible skilful workers who maintain currency and competency in order to deliver safe effective patient centered care. Nurses must continually build best practice into their care and acquire lifelong learning. Often this learning is acquired within the work environment and is facilitated by the clinical nurse educator. Understanding clinical nurses' values and needs of continuing education is necessary to ensure appropriate education service delivery and thus enhance patient care. Objectives: To explore clinical ward-based nurses' values and perceptions towards continuing education and what factors impact on continuing education in the ward. Design: A case study approach was utilized. Setting: A major teaching hospital in Melbourne, Australia. Participants: A range of clinical nursing staff (n = 23). Methods: Four focus groups and six semi-structured individual interviews were undertaken. Focus group interviews explored participants' values and perceptions on continuing education through a values clarification tool. Thematic analysis of interviews was undertaken to identify themes and cluster data. Results: Three central themes: ‘culture and attitudes’, ‘what is learning?’ and ‘being there–being seen’, emerged reflecting staffs' values and perceptions of education and learning in the workplace. Conclusions: Multiple factors influence ward nurses' ability and motivation to incorporate lifelong learning into their practice. Despite variance in nurses' values and perceptions of CE in clinical environments, CE was perceived as important. Nurses yearned for changes to facilitate lifelong learning and cultivate a learning culture. Clinical nurse educators need to be cognizant of adult learners' characteristics such as values, beliefs, needs and potential barriers, to effectively facilitate support in a challenging and complex learning environment. Organizational support is essential so ward managers in conjunction with educational departments can promote and sustain continuing education, lifelong learning and a culture conducive to learning. © 2013 Elsevier Ltd. All rights reserved.
Introduction The role of the Clinical Nurse Educator (CNE) in Australia is considered to be a provider of educational services for nurses, linking with the organizational and patients' needs. The UK role of Practice Education Facilitator (PEF) is similar although PEFs' role also includes mentoring and preceptorship training. Perceptions about education and the role of the CNE vary. There is uncertainty about the extent of the role, how education is delivered, and varying and competing needs of the individual, ward and organization. These elements impact on the culture of learning, and vicariously on patient care. The CNEs' role is therefore complex, with little to guide practice (Conway and Elwin, 2007). Misconceptions from ward nurses and
managers create further difficulty for CNEs to lead change (Conway and Elwin, 2007; Manley and McCormack, 2003). Nurses are required to be flexible, critical thinkers striving to deliver safe and effective patient centered care. Hence, fostering lifelong learning and educational opportunities within clinical practice is important. Facilitating this learning requires gaining nurses' acceptance and integration of education into their everyday practice and the ward team. There is, however, a scarcity of literature that examines nurses' needs and values of education provision and how this might contribute to nurses' professional development. Continuing education (CE), defined as post registration activities that facilitate learning within the workplace, can augment the professional self (Billett, 2004; Osmond, 2003). Background
⁎ Corresponding author. Tel.: +61 3 9902 4570. E-mail addresses: [email protected] (J.M. Newton), [email protected] (M. Govranos). 1 Tel.: +61 3 95943619. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.07.003
The current global challenges of economic downturn, cultural shifts, technological advancements and overpopulation have impacted on all workplaces, where adaptable, skillful workers engaged in continuous
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professional development are required (Bastable, 2008; Health Workforce Australia, 2011; Watson, 2003). The demanding, complex health care system of today has seen the nurse's role in Australia extended and expanded to a recognized professional, offering an essential element in managing patient care (Health Workforce Australia, 2011; Henderson and Winch, 2008; Newton et al., 2010). Nurses' scope of practice has and continues to evolve as they gain more accountability and autonomy. Post registration nursing education is predominantly undertaken in the clinical area as nurses prefer learning to occur in their workplace environment (Considine and Hood, 2000; Knapper, 2001). The clinical learning environment impacts on nurses' professional development and learning; multiple factors such as role clarity, quality of supervision, and opportunities for education influence learning (Hart and Rotem, 1995). Eraut's (2004, 2007) and Eraut et al.'s (2004) research on workplace learning highlights how organizational support including quality of management, leadership and senior staff, impacts on collegial support, learning opportunities and value of staff. This in turn affects staff motivation, empowerment and learning culture. Research also indicates that nurses' work environments generate high responsibility, excessive stress with immense workload and often limited support or time for reflection (Hart and Rotem, 1995; Holland et al., 2012; Hughes, 2005). The learning environment and culture are pivotal to improving learning and acknowledging nurses' own identity, expectations, role, and staff development (Eraut, 2007; Hart and Rotem, 1995; Manley and McCormack, 2003). Workplace learning research suggests that a ‘culture of learning’ needs to be embedded to enhance staff retention and job satisfaction (Henderson et al., 2010; Newton et al., 2010; Smedley and Morey, 2010). However, in doing so, due consideration needs to be given to how adults learn. Adult Learning and Lifelong Learning Adults engage in learning when they have reason to engage. This relates to their confidence and competence in relation to the subject matter, which includes when they are faced with a problem in real life contexts (Jarvis, 1987; Knowles et al., 2005). Education and effective teaching involve many different aspects and theories. It entails not only the ability, experience and style of the teacher but also learning style, motivation, and internal and external influences that mold the learner (Burns, 1995; Knowles et al., 2005). The aim of education is for learners to gain a deep, lifelong approach to learning. The notion of lifelong learning is often used with different understandings (Delors, 1996; Knapper, 2001). Education cannot be a once off experience and should not be just knowledge of a vocation such as nursing: it should be continuous and include skills so that one can consciously or unconsciously learn and train oneself (Burns, 2002; Knapper, 2001; Watson, 2003). Given the importance of lifelong learning and the large body of nurses in the healthcare workplace, it is important that nurses' values in relation to continuing clinical education are explored. Values and Beliefs Recent research on nursing education from the UK in relation to continuing professional development (CPD) reveals a close association with mandatory education (Osmond, 2003). The Australian Health Practitioner Regulation Agency (AHPRA) (2009) has adopted mandatory CPD guidelines. Yet, there is limited literature that focuses on nurses' beliefs and values of CE within the clinical setting. In a climate of workforce challenges within healthcare in Australia e.g. increasing patient acuity, high attrition, aging population (Health Workforce Australia, 2011) and internationally (Douglas, 2011); planning for the future requires development of workplace cultures
that value staff, support their professional development, lifelong learning, and educational leadership. Study Design Aims This qualitative, descriptive study sought to explore clinical ward based nurses' values and perceptions towards continuing education (CE) and professional development. Within one acute ward in a major teaching tertiary hospital in Victoria, Australia, the research sought to examine: 1. In what ways is education valued by nurses and how do they perceive their role in CE? 2. What factors, if any, impact on CE in the ward? and 3. What aspects of CE would nurses like to see developed in their ward? Study Population Permanent nursing staff (n = 50) employed on a medical–surgical ward; division one registered nurses (RN) and division two registered nurses (enrolled nurses, EN) were invited to participate. Nonpermanent or visiting staff members, such as casual nurses, those attached to other teams, and student nurses were excluded. Method The study utilized the theoretical framework of case study (Anthony and Jack, 2009; Baxter and Jack, 2008; Yin, 2009). The focus of the case was to examine ‘how’ nurses view and perceive CE, their experiences and ‘what’ they see as CE within the real-life context of their ward environment. Both focus groups and individual interviews were used as data collection methods. Four interactive focus groups with 23 nurses were held initially, followed by individual interviews (n = 6). The focus group discussions enabled group interaction where different ideas were put forward and discussed so that multiple truths and realities were gained (Lambert and Loiselle, 2008; Stewart et al., 2007; Patton, 2002). The groups were created using convenience sampling, being the nurses at work on that day. The four sessions were held over a number of days to enable the range of part-time and fulltime nursing staff the opportunity to participate and to ascertain the main themes/issues across the ward. Focus group participants reviewed the data and discussed major issues and emerging themes (Lambert and Loiselle, 2008, 2007; Stewart et al., 2007; Speziale and Carpenter, 2007) that the researchers subsequently incorporated into open-ended, one-to-one interview questions. The majority of staff were RNs from Australian backgrounds (see Table 1). Table 2 provides the focus group questions, which were open, unfinished statements for staff to add their ideas to. Interview participants were selected using stratified purposive sampling (Burns and Grove, 2007). Staff were selected according to their grade or level of experience and grade. Six categories were identified, enrolled nurse, graduate registered nurse, registered nurse, senior registered nurse, in-charge (registered nurse, associate nurse unit manages) and nurse unit manager (see Fig. 1). One representative from each group participated in conversational style discussions (Yin, 2009) to explore a more in-depth understanding of the emergent themes from the focus groups. Iterative analysis was conducted throughout the data collection. Data were noted if needed to be looked into further (including rival data), so that it could be explored at the subsequent focus groups and/or interviews (Merriam, 2009; Yin, 2009). Themes were gathered through reading and coding the data which entailed highlighting the
M. Govranos, J.M. Newton / Nurse Education Today 34 (2014) 655–660 Table 1 Demographics of focus group participants.
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parts of striking information using a few words, which were then compared between sub-units of data to reveal recurring categories or themes. Guided by the propositions and research questions, data was re-read, interviews listened to again and scrutinized further (Taylor et al., 2006; Yin, 2009).
Age
N
20–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60 60+ Unknown
8 3 3 2 4 1 0 1 0 1
Gender
N
Ethical approval was obtained from the Human Research Ethics Committee of the healthcare organization and university. Informed consent was gained from each participant to audio-tape the interviews and participants selected their own pseudonym for de-identification in the written transcripts.
Male Female
2 22
Findings
Hours
N
Full time Part time
19 4
Qualifications RN EN
21 2
Training
N
Australia New Zealand UK Philippines India Hospital trained
14 1 3 3 2 4
Year of qualification
N
1975 1980 1988 1991 1994 1996 2001 2005 2007 2008 2009
1 1 2 2 1 1 2 2 5 1 5
Time in current ward
N
b1 yr 1–2 2–3 3–5 5–7 7–10 10–15
10 4 3 4 1 1 0
Grade
#
ANUM CNS RN GNP EN
1 3 13 4 2
Table 2 Values clarification informed by Manley and McCormack (2003). I believe the purpose of CE is …. This can be achieved by …. The factors that enable effective CE are …. The factors that inhibit effective CE are …. I believe the role of the CNE includes …. I believe my role as a staff member includes ….
Ethical Considerations
Three themes were identified: culture and attitudes, what is learning, and being there–being seen, that encapsulate the central focus of clinical nursing staff's values and perceptions of CE. These themes offer insight into the nurses' values and perceptions and while they highlight a desire for a learning culture, the factors that impact and impede CE within the ward are also illustrated. To enable the participants' comments to be read in context, they are grouped according to broad categories of senior registered nurse division 1 (SRN1), junior registered nurse division 1 (JRN1), and registered nurse division 2 (RN2). Nicole, John and Vadah are SRN1s, Katie and Michelle are JRN1s and Gemini is an RN2. Focus group comments were unidentifiable, however pertinent participant quotes are included and labeled according to the focus group one through to four (FG1–FG4). Culture and Attitudes This theme centers on the nurses' perception of their role as a nurse and what value CE can add to this role. The contextual factors shape how the environment supports and influences the learning climate of the ward and the individual's view on learning may alter the prospect of CE. Underpinning the theme is the importance of education, and education versus the workplace. Focus group participants made comments such as a need to, ‘keep up to date with my career (FG1)’, ‘improving standards (FG4)’ and ‘excellence in providing quality care (FG1)’. One documented comment from FG1 was, ‘to continue to fulfill our duty of care to patients and to maintain/reinforce the knowledge previously learnt’, which illustrates individuals' attitudes which affect the motivation to improve and update knowledge. Conversely, some perceived CE as separate to the workplace environment as articulated in John's comment below: “the perception is often that education is interrupting the work [and] education is compartmentalized to the side … Education is one thing and this is about work and even though people might say I need to learn that to do my job, they don't look at a lot of education as work related.” The demands within the ward environment have fostered a culture of busyness; where tasks and patient care needs to be done within a timeframe. The following comments illustrate the issue of time as an elusive component in nurses' work, the inability to create space for education and how this culture is engrained from the time of undergraduate exposure: “Time is our biggest enemy” (Gemini). A sense of having to get everything done was ‘drummed’ into Michelle when she was a student, “You feel as nurses, you feel like you have to get everything done” (Michelle).
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Fig. 1. Levels of experience.
While Vadah acknowledged that: “Education is important, because the best way to see a patient walk out of this hospital is to prevent them getting that sick in the first place, and to do that you need to have good assessment skills, which comes from education and experience. Because at the end of the day this is not working in Kmart [a retail outlet], this is nursing, and we're working with very sick patients in this hospital”. The workplace appeared to create a dichotomy amongst this group of nurses with regard to whether it was a place of work or one of learning. These values and attitudes that create such a culture closely align with the participants' perceptions and expectations of learning. What is Learning The way CE is delivered and how it is presented influenced the nurses' perceptions and utilization of CE and learning. Five main delivery methods were identified within the ward setting. These were: in-service sessions, courses, one on one, self-directed learning and utilizing senior staff. Across the focus groups and interviews, in-service was one of the most discernible methods and often one of the first responses by participants to how CE is accomplished. The nature of in-service education does not always ensure that staff learn and engage. There is generally no perceived need to comprehend some in-service sessions; subsequently Vadah comments on the attitude of some staff, “I'm not getting assessed, so who cares? No one is going to know that I don't know; no one is going to know I've fallen asleep”. Self-directed learning was also seen as important as stated by Vadah: “people [should be] responsible for their own learning rather than being spoon fed, and that's a big problem, is there's a lot of people that don't feel they need to be educated”.
and spend hours on end doing self-directed learning… I just don't feel the motivation when I get home to use my personal time to slave away learning about things” (Michelle). One on one learning was also seen as important and “invaluable … a great way to learn” (John) though also as potentially “intimidating” and “resource demanding” (Nicole). Participants saw senior staff as a valuable and accessible resource. However they require training in facilitation and managerial support to be allocated appropriately so they may be able to help educate others. The clear focus of this theme is encapsulated in John's view that, “in a good ward everybody has a role in education”. The need to be ‘up-to date’ was a construct of this theme, and centered around the nurses' impetus to remain current and up to date. This need was associated with external influences, such as organizational and mandatory legislation, along with the intrinsic desire to engage in CE as shared by Gemini: CE “… maintains your skills … your professionalism … your confidence … it keeps your registration as well”. What did emerge in the analysis was the importance of CE being available which is described in the third theme. Being ‘There’–Being ‘Seen’ The desire for education to be readily available and easily accessible in this busy environment with competing agendas is the central tenet of this theme. The role of the CNE and how they interact with the staff in meeting their CE requirements, in particularly emerged as an important influence. As Vadah stated:
Conversely others thought that a balance needed to be made between work and learning:
“They've turned into more of a floater rather than an educator … also the way that our staff have been treating the educator, a lot of them are confused as to the role. So I think more of a role definition … and the educators really need to set boundaries … and support rather than do for”.
“… find a nice balance between getting your education within your work timeframe. I don't feel like I should have to go home
Competing expectations were apparent with some participants from FG3 wanting an educator to: ‘build a rapport’, ‘doesn't grill or
M. Govranos, J.M. Newton / Nurse Education Today 34 (2014) 655–660
probe too far but still push’; and others wanting the CNE to: ‘walk around talk to staff and make a bed … can approach them better’. Along with the degree of uncertainty about the CNE's characteristics and role definition, it was clear that nurses also expected CNEs to be ‘approachable, supportive, instill confidence and role model the gold standard’ (FG2). Inhibiting factors surrounding the CNE in the workplace John suggested that there: “… needs to be a closer link between management and education …” as change will not be possible if they are not linked. He states; “… education fails to capture the workplace context … I think that education works on the premise that it can stop and educate but the workplace, particularly a busy acute setting, doesn't stop … a lot of education could happen in the workplace as it's happening”. Importantly, CE needs to be available when needed and in a timely manner. Nicole proposed a way for CE can happen within the ward context is by: “… getting your senior staff away from all those acutely unwell patients and getting the junior staff in … The younger staff don't get any exposure to it and they have to learn just the same. They need to learn to become those senior nurses”. The ward environment provides many obstacles thus participants exhibited a desire for education to ‘be there’. To ensure that staff feel that CE and the CNE have a physical presence ‘being there’ and ‘being seen’ needs to be a reality of everyday practice.
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suggest nothing affects learning more strongly and unconsciously than the everyday circumstances of work, and the nature of challenges and opportunities that work creates; drives learning. Learning opportunities could be created in everyday practice by allocating senior staff to less acute patients and the novice nurse the more complex patients. Thus, fostering learning by providing novices with challenging patients with support from an individual with expertise. Such opportunities can be created where there is effective leadership and managerial support, which requires an organization that endorses learning (Douglas, 2011; Henderson et al., 2011; Manley et al., 2009). The role of the CNE was exposed as meaning something different for all nurses. CNEs need to investigate and define their role and how they approach CE within the ward context (Conway and Elwin, 2007). Such a multifaceted and complex role requires a skilled professional who can facilitate a learning culture where learning will be its own reward (Knowles et al., 2005; Conway and Elwin, 2007; Williams, 2010). Open discussions between CNE and staff around their values and beliefs in relation to CE may help bridge the gaps between learning and the workplace; and this empowerment of nurses is crucial for sustainable lifelong learning and making implicit learning explicit will foster cultural change. Unwin et al. (2007, 333) argue that organizations “differ in the way they create and manage themselves as learning environments”. The influence of the organization in which professionals practice and the work that they do can have a more substantial impact on continuing professional learning than any program of study (Boud and Hager, 2012). Thus it is important that healthcare organizations, government agencies, and the participants themselves are cognizant of this.
Discussion Limitations Working within the current complex health care system is proving difficult for nurses and is impacting on the assimilation of CE and learning. For nurses to maintain professional development they need CE to be integrated into the workplace. The findings of this study indicate that CE is seen by the majority of participants as a necessary element to being able to provide appropriate patient care. Yet, some nurses appeared apathetic to CE along with some inconsistency between many nurses' espoused values and beliefs with their actual practice. This could possibly be due to the environmental constraints and the competing priorities within a work shift such as time, minimal available support and complacency. Prior experiences with CE may also affect nurses' attitudes towards CE. Nurses who are highly motivated and appreciate CE, understand the link between CE and the workplace and try to manipulate the barriers so they can keep up to date and meet their learning needs (Jarvis, 1987; Dewing, 2008; Skar, 2010). However, valuing best practice and the importance of CE and its strategies, can be constrained by workplace barriers that impinge on nurses incorporating their values in daily work. Shifting priorities and time constraints are a realistic part of nurses' work and CNEs need to work within such restrictions. Time was one of the most noted barriers in this study and this is consistent with previous research (Henderson et al., 2011; Manley et al., 2009; Merriam et al., 2007). It is unlikely in such a culture of busyness that there will ever be protected education time and many staff do not have the ability to reflect on learning while managing rapidly changing situations. Similarly, Eraut et al. (2004) found issues with novice nurses who were “concerned not to look inadequate and to make a good impression as competent nurses”. These nurses felt that they had to get all tasks done within a given timeframe, with no time for reflection. If nurses are unable to reflect and realize learning opportunities then this learning goes unnoticed and practice becomes a habit rather than evidence based (Delors, 1996; Eraut, 2007; Hughes, 2005). Nurses are used to being passive learners (Williams, 2010) their assumptions about nursing care and learning need to be challenged and supported. As Boud and Hager (2012)
As a case study of one particular entity with small numbers of participants the ability to generalize these findings within other settings and wards is a significant limitation. The topic of CE values relates to the culture of a ward within one hospital and this might not be reflective of other wards in this particular healthcare organization or other organizations that maybe more open to learning and CE. Recommendations Further work is required to explore nurses' perceptions of continuing education across a range of clinical areas; and whether mandatory CPD has an influencing effect on their values. Reducing the compartmentalization of education and work by nurses requires attention by management and nursing education in offering support to promoting an integrated approach to clinical learning. Exploration of values and perceptions of the CNE and CE and organizational strategic goals may assist in finding a common vision. CNEs need to explore with ward nurses their values and beliefs so that barriers to CE can be addressed, to promote collaboration in creating a learning culture. Conclusion In considering CE it is important to acknowledge the learning possibilities that participation in everyday practice does or does not generate (Boud and Hager, 2012). Certainly in this study, the values clarification exercise challenged many nurses to uncover their beliefs within their practice setting, and how CE is integrated into their workplace culture. The role of the CNE was debated and questioned; illustrating the need for CNEs to have a clear role definition and be comfortable with their role. Given the global challenges and complexity of nurses' clinical work coupled with increasing mandatory CPD, research into nurses' values of CE is an essential requirement to ensure that their continuing professional development needs are met.
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Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Exploring ward nurses' perceptions of continuing education in clinical settings Melissa Govranos a,1, Jennifer M. Newton b,⁎ a b
Nursing and Midwifery Education and Strategy, Monash Health, 246 Clayton Rd, Clayton, Victoria 3168, Australia School of Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Bldg 13 C, Clayton Campus, Australia
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Article history: Accepted 2 July 2013 Keywords: Continuing education Professional development Nurse education Staff development Work-based learning
s u m m a r y Background: Health care systems demand that nurses are flexible skilful workers who maintain currency and competency in order to deliver safe effective patient centered care. Nurses must continually build best practice into their care and acquire lifelong learning. Often this learning is acquired within the work environment and is facilitated by the clinical nurse educator. Understanding clinical nurses' values and needs of continuing education is necessary to ensure appropriate education service delivery and thus enhance patient care. Objectives: To explore clinical ward-based nurses' values and perceptions towards continuing education and what factors impact on continuing education in the ward. Design: A case study approach was utilized. Setting: A major teaching hospital in Melbourne, Australia. Participants: A range of clinical nursing staff (n = 23). Methods: Four focus groups and six semi-structured individual interviews were undertaken. Focus group interviews explored participants' values and perceptions on continuing education through a values clarification tool. Thematic analysis of interviews was undertaken to identify themes and cluster data. Results: Three central themes: ‘culture and attitudes’, ‘what is learning?’ and ‘being there–being seen’, emerged reflecting staffs' values and perceptions of education and learning in the workplace. Conclusions: Multiple factors influence ward nurses' ability and motivation to incorporate lifelong learning into their practice. Despite variance in nurses' values and perceptions of CE in clinical environments, CE was perceived as important. Nurses yearned for changes to facilitate lifelong learning and cultivate a learning culture. Clinical nurse educators need to be cognizant of adult learners' characteristics such as values, beliefs, needs and potential barriers, to effectively facilitate support in a challenging and complex learning environment. Organizational support is essential so ward managers in conjunction with educational departments can promote and sustain continuing education, lifelong learning and a culture conducive to learning. © 2013 Elsevier Ltd. All rights reserved.
Introduction The role of the Clinical Nurse Educator (CNE) in Australia is considered to be a provider of educational services for nurses, linking with the organizational and patients' needs. The UK role of Practice Education Facilitator (PEF) is similar although PEFs' role also includes mentoring and preceptorship training. Perceptions about education and the role of the CNE vary. There is uncertainty about the extent of the role, how education is delivered, and varying and competing needs of the individual, ward and organization. These elements impact on the culture of learning, and vicariously on patient care. The CNEs' role is therefore complex, with little to guide practice (Conway and Elwin, 2007). Misconceptions from ward nurses and
managers create further difficulty for CNEs to lead change (Conway and Elwin, 2007; Manley and McCormack, 2003). Nurses are required to be flexible, critical thinkers striving to deliver safe and effective patient centered care. Hence, fostering lifelong learning and educational opportunities within clinical practice is important. Facilitating this learning requires gaining nurses' acceptance and integration of education into their everyday practice and the ward team. There is, however, a scarcity of literature that examines nurses' needs and values of education provision and how this might contribute to nurses' professional development. Continuing education (CE), defined as post registration activities that facilitate learning within the workplace, can augment the professional self (Billett, 2004; Osmond, 2003). Background
⁎ Corresponding author. Tel.: +61 3 9902 4570. E-mail addresses: [email protected] (J.M. Newton), [email protected] (M. Govranos). 1 Tel.: +61 3 95943619. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.07.003
The current global challenges of economic downturn, cultural shifts, technological advancements and overpopulation have impacted on all workplaces, where adaptable, skillful workers engaged in continuous
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professional development are required (Bastable, 2008; Health Workforce Australia, 2011; Watson, 2003). The demanding, complex health care system of today has seen the nurse's role in Australia extended and expanded to a recognized professional, offering an essential element in managing patient care (Health Workforce Australia, 2011; Henderson and Winch, 2008; Newton et al., 2010). Nurses' scope of practice has and continues to evolve as they gain more accountability and autonomy. Post registration nursing education is predominantly undertaken in the clinical area as nurses prefer learning to occur in their workplace environment (Considine and Hood, 2000; Knapper, 2001). The clinical learning environment impacts on nurses' professional development and learning; multiple factors such as role clarity, quality of supervision, and opportunities for education influence learning (Hart and Rotem, 1995). Eraut's (2004, 2007) and Eraut et al.'s (2004) research on workplace learning highlights how organizational support including quality of management, leadership and senior staff, impacts on collegial support, learning opportunities and value of staff. This in turn affects staff motivation, empowerment and learning culture. Research also indicates that nurses' work environments generate high responsibility, excessive stress with immense workload and often limited support or time for reflection (Hart and Rotem, 1995; Holland et al., 2012; Hughes, 2005). The learning environment and culture are pivotal to improving learning and acknowledging nurses' own identity, expectations, role, and staff development (Eraut, 2007; Hart and Rotem, 1995; Manley and McCormack, 2003). Workplace learning research suggests that a ‘culture of learning’ needs to be embedded to enhance staff retention and job satisfaction (Henderson et al., 2010; Newton et al., 2010; Smedley and Morey, 2010). However, in doing so, due consideration needs to be given to how adults learn. Adult Learning and Lifelong Learning Adults engage in learning when they have reason to engage. This relates to their confidence and competence in relation to the subject matter, which includes when they are faced with a problem in real life contexts (Jarvis, 1987; Knowles et al., 2005). Education and effective teaching involve many different aspects and theories. It entails not only the ability, experience and style of the teacher but also learning style, motivation, and internal and external influences that mold the learner (Burns, 1995; Knowles et al., 2005). The aim of education is for learners to gain a deep, lifelong approach to learning. The notion of lifelong learning is often used with different understandings (Delors, 1996; Knapper, 2001). Education cannot be a once off experience and should not be just knowledge of a vocation such as nursing: it should be continuous and include skills so that one can consciously or unconsciously learn and train oneself (Burns, 2002; Knapper, 2001; Watson, 2003). Given the importance of lifelong learning and the large body of nurses in the healthcare workplace, it is important that nurses' values in relation to continuing clinical education are explored. Values and Beliefs Recent research on nursing education from the UK in relation to continuing professional development (CPD) reveals a close association with mandatory education (Osmond, 2003). The Australian Health Practitioner Regulation Agency (AHPRA) (2009) has adopted mandatory CPD guidelines. Yet, there is limited literature that focuses on nurses' beliefs and values of CE within the clinical setting. In a climate of workforce challenges within healthcare in Australia e.g. increasing patient acuity, high attrition, aging population (Health Workforce Australia, 2011) and internationally (Douglas, 2011); planning for the future requires development of workplace cultures
that value staff, support their professional development, lifelong learning, and educational leadership. Study Design Aims This qualitative, descriptive study sought to explore clinical ward based nurses' values and perceptions towards continuing education (CE) and professional development. Within one acute ward in a major teaching tertiary hospital in Victoria, Australia, the research sought to examine: 1. In what ways is education valued by nurses and how do they perceive their role in CE? 2. What factors, if any, impact on CE in the ward? and 3. What aspects of CE would nurses like to see developed in their ward? Study Population Permanent nursing staff (n = 50) employed on a medical–surgical ward; division one registered nurses (RN) and division two registered nurses (enrolled nurses, EN) were invited to participate. Nonpermanent or visiting staff members, such as casual nurses, those attached to other teams, and student nurses were excluded. Method The study utilized the theoretical framework of case study (Anthony and Jack, 2009; Baxter and Jack, 2008; Yin, 2009). The focus of the case was to examine ‘how’ nurses view and perceive CE, their experiences and ‘what’ they see as CE within the real-life context of their ward environment. Both focus groups and individual interviews were used as data collection methods. Four interactive focus groups with 23 nurses were held initially, followed by individual interviews (n = 6). The focus group discussions enabled group interaction where different ideas were put forward and discussed so that multiple truths and realities were gained (Lambert and Loiselle, 2008; Stewart et al., 2007; Patton, 2002). The groups were created using convenience sampling, being the nurses at work on that day. The four sessions were held over a number of days to enable the range of part-time and fulltime nursing staff the opportunity to participate and to ascertain the main themes/issues across the ward. Focus group participants reviewed the data and discussed major issues and emerging themes (Lambert and Loiselle, 2008, 2007; Stewart et al., 2007; Speziale and Carpenter, 2007) that the researchers subsequently incorporated into open-ended, one-to-one interview questions. The majority of staff were RNs from Australian backgrounds (see Table 1). Table 2 provides the focus group questions, which were open, unfinished statements for staff to add their ideas to. Interview participants were selected using stratified purposive sampling (Burns and Grove, 2007). Staff were selected according to their grade or level of experience and grade. Six categories were identified, enrolled nurse, graduate registered nurse, registered nurse, senior registered nurse, in-charge (registered nurse, associate nurse unit manages) and nurse unit manager (see Fig. 1). One representative from each group participated in conversational style discussions (Yin, 2009) to explore a more in-depth understanding of the emergent themes from the focus groups. Iterative analysis was conducted throughout the data collection. Data were noted if needed to be looked into further (including rival data), so that it could be explored at the subsequent focus groups and/or interviews (Merriam, 2009; Yin, 2009). Themes were gathered through reading and coding the data which entailed highlighting the
M. Govranos, J.M. Newton / Nurse Education Today 34 (2014) 655–660 Table 1 Demographics of focus group participants.
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parts of striking information using a few words, which were then compared between sub-units of data to reveal recurring categories or themes. Guided by the propositions and research questions, data was re-read, interviews listened to again and scrutinized further (Taylor et al., 2006; Yin, 2009).
Age
N
20–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60 60+ Unknown
8 3 3 2 4 1 0 1 0 1
Gender
N
Ethical approval was obtained from the Human Research Ethics Committee of the healthcare organization and university. Informed consent was gained from each participant to audio-tape the interviews and participants selected their own pseudonym for de-identification in the written transcripts.
Male Female
2 22
Findings
Hours
N
Full time Part time
19 4
Qualifications RN EN
21 2
Training
N
Australia New Zealand UK Philippines India Hospital trained
14 1 3 3 2 4
Year of qualification
N
1975 1980 1988 1991 1994 1996 2001 2005 2007 2008 2009
1 1 2 2 1 1 2 2 5 1 5
Time in current ward
N
b1 yr 1–2 2–3 3–5 5–7 7–10 10–15
10 4 3 4 1 1 0
Grade
#
ANUM CNS RN GNP EN
1 3 13 4 2
Table 2 Values clarification informed by Manley and McCormack (2003). I believe the purpose of CE is …. This can be achieved by …. The factors that enable effective CE are …. The factors that inhibit effective CE are …. I believe the role of the CNE includes …. I believe my role as a staff member includes ….
Ethical Considerations
Three themes were identified: culture and attitudes, what is learning, and being there–being seen, that encapsulate the central focus of clinical nursing staff's values and perceptions of CE. These themes offer insight into the nurses' values and perceptions and while they highlight a desire for a learning culture, the factors that impact and impede CE within the ward are also illustrated. To enable the participants' comments to be read in context, they are grouped according to broad categories of senior registered nurse division 1 (SRN1), junior registered nurse division 1 (JRN1), and registered nurse division 2 (RN2). Nicole, John and Vadah are SRN1s, Katie and Michelle are JRN1s and Gemini is an RN2. Focus group comments were unidentifiable, however pertinent participant quotes are included and labeled according to the focus group one through to four (FG1–FG4). Culture and Attitudes This theme centers on the nurses' perception of their role as a nurse and what value CE can add to this role. The contextual factors shape how the environment supports and influences the learning climate of the ward and the individual's view on learning may alter the prospect of CE. Underpinning the theme is the importance of education, and education versus the workplace. Focus group participants made comments such as a need to, ‘keep up to date with my career (FG1)’, ‘improving standards (FG4)’ and ‘excellence in providing quality care (FG1)’. One documented comment from FG1 was, ‘to continue to fulfill our duty of care to patients and to maintain/reinforce the knowledge previously learnt’, which illustrates individuals' attitudes which affect the motivation to improve and update knowledge. Conversely, some perceived CE as separate to the workplace environment as articulated in John's comment below: “the perception is often that education is interrupting the work [and] education is compartmentalized to the side … Education is one thing and this is about work and even though people might say I need to learn that to do my job, they don't look at a lot of education as work related.” The demands within the ward environment have fostered a culture of busyness; where tasks and patient care needs to be done within a timeframe. The following comments illustrate the issue of time as an elusive component in nurses' work, the inability to create space for education and how this culture is engrained from the time of undergraduate exposure: “Time is our biggest enemy” (Gemini). A sense of having to get everything done was ‘drummed’ into Michelle when she was a student, “You feel as nurses, you feel like you have to get everything done” (Michelle).
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Fig. 1. Levels of experience.
While Vadah acknowledged that: “Education is important, because the best way to see a patient walk out of this hospital is to prevent them getting that sick in the first place, and to do that you need to have good assessment skills, which comes from education and experience. Because at the end of the day this is not working in Kmart [a retail outlet], this is nursing, and we're working with very sick patients in this hospital”. The workplace appeared to create a dichotomy amongst this group of nurses with regard to whether it was a place of work or one of learning. These values and attitudes that create such a culture closely align with the participants' perceptions and expectations of learning. What is Learning The way CE is delivered and how it is presented influenced the nurses' perceptions and utilization of CE and learning. Five main delivery methods were identified within the ward setting. These were: in-service sessions, courses, one on one, self-directed learning and utilizing senior staff. Across the focus groups and interviews, in-service was one of the most discernible methods and often one of the first responses by participants to how CE is accomplished. The nature of in-service education does not always ensure that staff learn and engage. There is generally no perceived need to comprehend some in-service sessions; subsequently Vadah comments on the attitude of some staff, “I'm not getting assessed, so who cares? No one is going to know that I don't know; no one is going to know I've fallen asleep”. Self-directed learning was also seen as important as stated by Vadah: “people [should be] responsible for their own learning rather than being spoon fed, and that's a big problem, is there's a lot of people that don't feel they need to be educated”.
and spend hours on end doing self-directed learning… I just don't feel the motivation when I get home to use my personal time to slave away learning about things” (Michelle). One on one learning was also seen as important and “invaluable … a great way to learn” (John) though also as potentially “intimidating” and “resource demanding” (Nicole). Participants saw senior staff as a valuable and accessible resource. However they require training in facilitation and managerial support to be allocated appropriately so they may be able to help educate others. The clear focus of this theme is encapsulated in John's view that, “in a good ward everybody has a role in education”. The need to be ‘up-to date’ was a construct of this theme, and centered around the nurses' impetus to remain current and up to date. This need was associated with external influences, such as organizational and mandatory legislation, along with the intrinsic desire to engage in CE as shared by Gemini: CE “… maintains your skills … your professionalism … your confidence … it keeps your registration as well”. What did emerge in the analysis was the importance of CE being available which is described in the third theme. Being ‘There’–Being ‘Seen’ The desire for education to be readily available and easily accessible in this busy environment with competing agendas is the central tenet of this theme. The role of the CNE and how they interact with the staff in meeting their CE requirements, in particularly emerged as an important influence. As Vadah stated:
Conversely others thought that a balance needed to be made between work and learning:
“They've turned into more of a floater rather than an educator … also the way that our staff have been treating the educator, a lot of them are confused as to the role. So I think more of a role definition … and the educators really need to set boundaries … and support rather than do for”.
“… find a nice balance between getting your education within your work timeframe. I don't feel like I should have to go home
Competing expectations were apparent with some participants from FG3 wanting an educator to: ‘build a rapport’, ‘doesn't grill or
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probe too far but still push’; and others wanting the CNE to: ‘walk around talk to staff and make a bed … can approach them better’. Along with the degree of uncertainty about the CNE's characteristics and role definition, it was clear that nurses also expected CNEs to be ‘approachable, supportive, instill confidence and role model the gold standard’ (FG2). Inhibiting factors surrounding the CNE in the workplace John suggested that there: “… needs to be a closer link between management and education …” as change will not be possible if they are not linked. He states; “… education fails to capture the workplace context … I think that education works on the premise that it can stop and educate but the workplace, particularly a busy acute setting, doesn't stop … a lot of education could happen in the workplace as it's happening”. Importantly, CE needs to be available when needed and in a timely manner. Nicole proposed a way for CE can happen within the ward context is by: “… getting your senior staff away from all those acutely unwell patients and getting the junior staff in … The younger staff don't get any exposure to it and they have to learn just the same. They need to learn to become those senior nurses”. The ward environment provides many obstacles thus participants exhibited a desire for education to ‘be there’. To ensure that staff feel that CE and the CNE have a physical presence ‘being there’ and ‘being seen’ needs to be a reality of everyday practice.
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suggest nothing affects learning more strongly and unconsciously than the everyday circumstances of work, and the nature of challenges and opportunities that work creates; drives learning. Learning opportunities could be created in everyday practice by allocating senior staff to less acute patients and the novice nurse the more complex patients. Thus, fostering learning by providing novices with challenging patients with support from an individual with expertise. Such opportunities can be created where there is effective leadership and managerial support, which requires an organization that endorses learning (Douglas, 2011; Henderson et al., 2011; Manley et al., 2009). The role of the CNE was exposed as meaning something different for all nurses. CNEs need to investigate and define their role and how they approach CE within the ward context (Conway and Elwin, 2007). Such a multifaceted and complex role requires a skilled professional who can facilitate a learning culture where learning will be its own reward (Knowles et al., 2005; Conway and Elwin, 2007; Williams, 2010). Open discussions between CNE and staff around their values and beliefs in relation to CE may help bridge the gaps between learning and the workplace; and this empowerment of nurses is crucial for sustainable lifelong learning and making implicit learning explicit will foster cultural change. Unwin et al. (2007, 333) argue that organizations “differ in the way they create and manage themselves as learning environments”. The influence of the organization in which professionals practice and the work that they do can have a more substantial impact on continuing professional learning than any program of study (Boud and Hager, 2012). Thus it is important that healthcare organizations, government agencies, and the participants themselves are cognizant of this.
Discussion Limitations Working within the current complex health care system is proving difficult for nurses and is impacting on the assimilation of CE and learning. For nurses to maintain professional development they need CE to be integrated into the workplace. The findings of this study indicate that CE is seen by the majority of participants as a necessary element to being able to provide appropriate patient care. Yet, some nurses appeared apathetic to CE along with some inconsistency between many nurses' espoused values and beliefs with their actual practice. This could possibly be due to the environmental constraints and the competing priorities within a work shift such as time, minimal available support and complacency. Prior experiences with CE may also affect nurses' attitudes towards CE. Nurses who are highly motivated and appreciate CE, understand the link between CE and the workplace and try to manipulate the barriers so they can keep up to date and meet their learning needs (Jarvis, 1987; Dewing, 2008; Skar, 2010). However, valuing best practice and the importance of CE and its strategies, can be constrained by workplace barriers that impinge on nurses incorporating their values in daily work. Shifting priorities and time constraints are a realistic part of nurses' work and CNEs need to work within such restrictions. Time was one of the most noted barriers in this study and this is consistent with previous research (Henderson et al., 2011; Manley et al., 2009; Merriam et al., 2007). It is unlikely in such a culture of busyness that there will ever be protected education time and many staff do not have the ability to reflect on learning while managing rapidly changing situations. Similarly, Eraut et al. (2004) found issues with novice nurses who were “concerned not to look inadequate and to make a good impression as competent nurses”. These nurses felt that they had to get all tasks done within a given timeframe, with no time for reflection. If nurses are unable to reflect and realize learning opportunities then this learning goes unnoticed and practice becomes a habit rather than evidence based (Delors, 1996; Eraut, 2007; Hughes, 2005). Nurses are used to being passive learners (Williams, 2010) their assumptions about nursing care and learning need to be challenged and supported. As Boud and Hager (2012)
As a case study of one particular entity with small numbers of participants the ability to generalize these findings within other settings and wards is a significant limitation. The topic of CE values relates to the culture of a ward within one hospital and this might not be reflective of other wards in this particular healthcare organization or other organizations that maybe more open to learning and CE. Recommendations Further work is required to explore nurses' perceptions of continuing education across a range of clinical areas; and whether mandatory CPD has an influencing effect on their values. Reducing the compartmentalization of education and work by nurses requires attention by management and nursing education in offering support to promoting an integrated approach to clinical learning. Exploration of values and perceptions of the CNE and CE and organizational strategic goals may assist in finding a common vision. CNEs need to explore with ward nurses their values and beliefs so that barriers to CE can be addressed, to promote collaboration in creating a learning culture. Conclusion In considering CE it is important to acknowledge the learning possibilities that participation in everyday practice does or does not generate (Boud and Hager, 2012). Certainly in this study, the values clarification exercise challenged many nurses to uncover their beliefs within their practice setting, and how CE is integrated into their workplace culture. The role of the CNE was debated and questioned; illustrating the need for CNEs to have a clear role definition and be comfortable with their role. Given the global challenges and complexity of nurses' clinical work coupled with increasing mandatory CPD, research into nurses' values of CE is an essential requirement to ensure that their continuing professional development needs are met.
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