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Nurses’ experiences of continuing professional development
Nurse Education Today (2007) 27, 602–609
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Nurses’ experiences of continuing professional development Dinah Gould *, Nicholas Drey, Emma-Jane Berridge St Bartholomew’s School of Nursing and Midwifery, 20 Street Bartholomew’s Close, City University, London EC1 A7QN, United Kingdom Accepted 29 August 2006
KEYWORDS
Summary Continuing professional development is regarded as part of the nursing role in the National Health Service. Health policy in the United Kingdom is built on the assumption that nurses’ roles can be extended through continuing professional development which is also considered to be a key factor in nursing retention. Previous research has considered the provision of learning mainly from the perspective of managers and education providers. The purpose of this paper is to explore nurses’ experiences of continuing professional development. The results presented in this paper form part of a larger survey (n = 451, response rate = 64.9%) designed to examine opportunities for continuing professional development and factors encouraging and discouraging uptake. An unexpectedly high number of respondents (n = 125, 27.7%) commented extensively on their personal experiences of continuing professional development. These comments were analysed inductively. Five main themes emerged: who and what is continuing professional development for?; accessing continuing professional development; one size does not fit all; managing work, life and doing continuing professional development; and making the best of continuing professional development. Most responses were positive, but the demands of taking courses were perceived to encroach on life outside work, especially the need to complete lengthy assignments. Managers were perceived to operate as the gatekeepers to course admission and opportunities to implement new knowledge and expertise. No comments were received concerning the role of education staff in continuing professional development. c 2006 Elsevier Ltd. All rights reserved.
Post-registration nursing education; Continuing professional development
Introduction * Corresponding author. Tel.: +44 0207 040 5449; fax: +44 0207 040 8888. E-mail address: [email protected] (D. Gould).
In the National Health Service (NHS) the Agenda for Change reforms have linked nurses’ pay and progression to their ability to demonstrate advance-
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.08.021
Nurses’ experiences of continuing professional development ments in clinical expertise and knowledge (Department of Health, 2003). Thus continuing professional development (CPD) has become an explicit part of the nursing role. Much has been written about CPD from the perspective of managers and nurse educators (Furze and Pearcey, 1999; Lawton and Wimpenny, 2003; Gould et al., 2004a), but accounts of qualified nurses’ experiences are poorly represented. Numerous studies include student evaluations, but are limited because they obtain information about the merits of the course from a managerial, educational and occasionally service user perspective (see for example Matthews-Smith et al., 2001; Smith and Topping, 2001). Recently Ellis and Nolan (2005) have made a valuable attempt to fill this gap. Their in-depth qualitative study illustrates the role played by managers deciding who should undertake CPD and providing opportunities to implement newly acquired expertise on return to clinical practice. The drawback of this study is that it is small scale, reflecting the opinions of only a select number of nurses in relation to a single course. The results of a questionnaire study by Hughes (2005), although obtaining data from 200 staff, obtained detailed information from only eight people. The purpose of this paper is to explore nurses’ experiences of continuing professional development. The results presented in this paper form part of a larger survey (n = 451, response rate = 64.9%) designed to examine opportunities for continuing professional development and factors encouraging and discouraging uptake. An unexpectedly high number of respondents (n = 125, 27.7%) commented extensively on their personal experiences of continuing professional development. These comments were analysed inductively. The main survey findings are discussed elsewhere.
Literature review CPD is considered essential for all health workers in the NHS Plan (Department of Health, 2000) and numerous other government documents (see for example Department of Health, 1998; Department of Health, 1999; Department of Health, 2001; National Audit Commission, 2001) because of its importance in the delivery of safe and effective care and its supposed role in securing job satisfaction and reduced attrition (Department of Health, 2003). This belief has been strengthened by research demonstrating links between job satisfaction with opportunities to undertake CPD (Tovey
603
and Adams, 1999) and nursing retention (Shields and Ward, 2001). There are concerns that opportunities to undertake CPD are reduced for nurses working exclusively at night, part-time (Larcombe and Maggs, 1991; Barriball and While, 1996) and for those approaching retirement (Watson et al., 2003), thus placing them at disadvantage. A different view has been taken by Friedman and Phillips (2004) who point out that although widely promoted by professional bodies throughout the United Kingdom (UK) and by the government, CPD is in fact poorly defined, with confusion about its purpose in both the academic and practitioner literature, especially in relation to nursing. This is reflected in reviews of the literature (Furze and Pearcey, 1999; Lawton and Wimpenny, 2003; Gould et al., 2004a) which suggest ambivalence on the part of managers and educators concerning whether CPD is intended primarily to increase service provision by increasing the range and repertoire of nursing skills or has a role in career and personal progression. There are reports of resentment among nurses who perceive that their personal needs are becoming overlooked by those of the service (Hicks and Hennessy, 1997) and some indication that heavy workload and absence of colleagues to cover the work (‘backfill’) prevent uptake of CPD (Shields, 2002). A recent qualitative study exploring the commissioning process also suggests that longer courses with academic emphasis are being promoted at the expense of those intended primarily to promote clinical expertise (Gould et al., 2004b). In this study university staff discussed the challenges of supporting post-registration students with inadequate study skills and the difficulty of making some types of course and assessment methods appear relevant to clinical work. This finding ties in with the findings of a growing body of literature suggesting that mature students in higher education have special needs which must be met by academic staff to enable them to perform well (Pascall and Cox, 1993). Mature pre-registration nursing students experience additional problems because of the physically and emotionally demanding nature of clinical placements and the need to travel to different venues (Glacklin and Glacklin, 1998; Kevern and Webb, 2005). In contrast little has been written about the challenges faced by qualified nurses undertaking CPD despite a requirement to engage in life long study and professional updating. This omission is surprising given the well documented problems encountered by working nurses with young families, the impact this is believed to have on the retention of experienced practitioners (Lader, 1995; Buchan and Seccombe, 2004) and the
604 tensions experienced when attempting to balance the demands of work and home life (Majomi et al., 2003).
The study Aim The aim of this part of the study was to explore qualified nurses’ experiences of CPD.
Study design The main study was undertaken with nurses (grade D-I) employed in three acute NHS trusts in London. Questionnaires were distributed via the internal hospital post to a random 10% sample of eligible nurses identified from the payroll. Each questionnaire was coded to preserve the anonymity of the respondent while allowing the research team to identify non-returns. Three reminders were sent. Completed questionnaires and consent forms were returned in sealed envelopes. Respondents were asked to state which long and short courses, study days and other learning opportunities they had received during the last twelve months. An open question at the end of the survey instrument invited comments. Of the 695 questionnaires dispatched, 451 (64.9 %) were returned and all were fully completed and usable. One hundred and twenty five (27.7%) provided detailed comments in response to the open question.
Ethical considerations Permission to undertake the study was granted by the multi-regional ethics committee serving the NHS trusts. All respondents were assured that the data would be treated in strict confidence and their identity as well as the identity of their institutions would not be disclosed in the final report or publications. All respondents received written information about the project. A consent form was included with the questionnaire and returned in the same envelope.
Analysis of the qualitative data The researchers read and reread each response to the open question independently to develop an overall impression of the data. They then worked together to code the content of each response. Significant ‘units of meaning’ (phrases, sentences, paragraphs) were highlighted, and interpretative
D. Gould et al. codes created (Miles and Huberman, 1994). The main themes emerging from each response were identified by bringing these codes into provisional relational groupings. Once each response had been examined and coded, it was possible to bring emergent themes from all the responses together into broader, over-arching categories. In a subsequent exercise, the responses were read and reread to explore and refine these tentative categories. Patterns, themes and regularities were sought, as well as contrasts, paradoxes and irregularities (Delamont, 1992). Through discussion between the researchers, categories were added and merged and interpretations refined to allow similarities and divergences of opinion to be noted and discussed. Analysis of the quantitative data and presentation of these findings are beyond the scope of this paper.
Findings Table 1 shows the characteristics of the sample overall. As expected, most respondents were women (n = 384, 85.1%). The majority (n = 292, 65.2%) were under forty years of age: very few nurses were under 25 (n = 29, 6.4%) or over 50 (n = 43, 9.5%). Over half the sample described themselves as White Caucasian (n = 245, 54.3%); 91 (20.2%) described themselves as Black; 68 (15.1%) described themselves as Asian; and 43 (9.5%) placed themselves in none of these categories. Four nurses did not reveal their ethnicity. A third were educated to degree level (n = 149, 33.0%) and a few to masters level (n = 36, 8.0%). Less than half (n = 206, 46.8%) had been qualified for more than 12 years. However, most (n = 284, 63%) had worked in their current trust for at least three years and a third were employed in senior grades (G,H and I). Most were employed fulltime (n = 392, 87.9%). Response rate was similar across all there trusts. Very few comments reflected completely negative opinions about CPD, but the majority of respondents indicated that although important for the sake of the service and the individual, pursuing CPD may have unintended consequences, some of which can be negative. Five main themes emerged from the data:
Who and what is CPD for? Accessing CPD. One size does not fit all. Managing work, life and doing CPD. Making the best of CPD.
Nurses’ experiences of continuing professional development Table 1
605
Characteristic of the sample
Variable
Trust 1 N (%)
Trust 2 N (%)
Trust 3 N (%)
All N (%)
Gender Male Female
17 (14.2) 103 (85.8)
13 (10.6) 108 (87.8)
32 (15.4) 173 (83.2)
62 (13.7) 384 (85.1)
Age* 21–25 26–30 31–40 41–50 >50
6 (5.0) 16 (13.3) 51 (42.5) 39 (32.5) 8 (6.7)
4 (3.3) 14 (11.4) 58 (47.2) 34 (27.6) 12 (9.8)
19 (9.1) 44 (21.2) 80 (38.5) 40 (19.2) 23 (11.1)
Ethnicity* Asian Black Other White
8 (6.7) 24 (20.0) 11 (9.2) 76 (63.3)
23 43 12 44
Education (highest level)* Registered Nurse (Diploma) Degree Masters*
72 (60.0) 30 (25.0) 18 (15.0)
87 (70.7) 31 (25.2) 5 (4.1)
122 (58.7) 73 (35.1) 13 (6.3)
Time Qualified (yrs)* Median (IQR)
13 (11.00)
13 (12.25)
10 (15)
12 (13)
Time employed by trust <6 mths 6 to 12 mths 1–2 yrs 3–5 yrs >5 yrs
7 (5.8) 9 (7.5) 23 (19.2) 30 (25.0) 51 (42.5)
6 (4.9) 19 (15.6) 24 (19.7) 35 (28.7) 38 (31.1)
3 (1.4) 21 (10.1) 53 (25.6) 63 (30.4) 67 (32.4)
16 49 100 128 156
(3.6) (10.9) (22.3) (28.5) (34.7)
Grade* D E F G H I
14 (11.7) 15 (12.5) 22 (18.3) 31 (25.8) 30 (25.0) 8 (6.7)
18 (14.8) 34 (27.9) 29 (23.8) 23 (18.9) 14 (11.5) 4 (3.3)
44 (21.3) 66 (31.9) 43 (20.8) 35 (16.9) 17 (8.2) 2 (1.0)
76 115 94 89 61 14
(16.9) (25.6) (20.9) (19.8) (13.6) (3.1)
106 (89.8) 12 (10.2)
107 (87.0) 16 (13.0)
179 (87.3) 26 (12.7)
Hours Full-time Part-time *
(18.7) (35.0) (9.8) (35.8)
37 24 20 125
(17.8) (11.5) (9.6) (60.1)
29 74 189 113 43
(6.4) (16.4) (41.9) (25.1) (9.5)
68 91 43 245
(15.1) (20.2) (9.5) (54.3)
281 (62.3) 134 (29.7) 36 (8.0)
392 (87.9) 54 (12.1)
Significant differences between the trusts.
Who and what is CPD for? Respondents thought that CPD plays an important role in enhancing service provision and maintaining safety for patients and nurses: ‘CPD helps nurses keep up to date and avoid mistakes which put patients at risk’. Links were made between CPD and clinical governance and the role of CPD bridging the theorypractice gap. The importance of maintaining skills and remaining professionally updated was ex-
pressed explicitly by some nurses and was implicit in the comments offered by others. CPE was also considered to play a key role in career and personal development: ‘CPD is vitally important to me personally and professionally and benefits both’. A number of respondents dwelt on the need for staff to feel ‘valued’ and ‘motivated’ through opportunities to undertake CPD. This was closely related to awareness of the need to improve retention, especially of experienced nurses.
606
Accessing continuing professional development Providing study leave has important and well documented resource implications for managers in the NHS (Gould et al., 2004b). These were all reflected in the comments offered by respondents in this study. There were reports of not being able to undertake CPD through lack of staff to fill the gap in the workforce; course cancellation by education providers through lack of uptake by other practitioners; a dearth of places on courses in high demand, especially those with the potential to enhance career progression; and difficulties of access experienced by particular groups including: part-time nurses; those working exclusively at night and the weekend; and those nearing retirement. A number of new reasons for poor access also emerged. There was some perception that opportunity to undertake CPD formed an important part of organisational propaganda promulgated by managers in the drive to attract nurses to the trusts. Once they joined the workforce, some respondents concluded that ‘lip service’ was paid to course applications. This became a powerful source of resentment in some cases: ‘Nurses need to be supported and valued for their efforts or they will leave . . . I thought I would be happy in this trust, but the policies (for CPD) don’t apply in reality . . . they are only good in writing’. Inequality of one form or another was also reported as a barrier to accessing CPD. There were sporadic examples of failure to access training events because managers were not supportive to the individual. In a few instances respondents suggested that managers denied access because they would be threatened by the superior knowledge that subordinates would gain. Implicit in this suggestion is that CPD has the potential to be used as a management tool with the capacity to reward or penalise individuals. ‘Education is often used as a stick to beat staff . . . managers control access to courses. Career promotion is used to keep staff in line’. Some respondents holding the post of sister or charge nurse attributed lack of opportunity to the indispensable nature of their role as lynchpin running the ward or department. Whether this was seen as a bad thing or just an inevitable consequence of occupying such a key role was not entirely apparent: ‘I always put my staff first for training opportunities as I am the most senior. It means I’m often behind them in terms of the latest information. I can’t go on courses – I have to supervise the ward’.
D. Gould et al. A few respondents reported that the university application procedure was lengthy and bureaucratic, operating as a disincentive to future course applications.
One size does not fit all This theme related to perceptions that the most effective mode of delivery depends on the type of learning opportunity that the CPD is intended to offer. Classroom-based courses might meet the needs of one type of learning or the preferences of a given individual, but would not be the most effective or preferred approach of others. Workbased learning was regarded by many nurses as at least as important as classroom-based opportunities. Some respondents felt that it no longer received the emphasis it should, with missed opportunities for staff development: ‘I feel on the job learning . . . has the greatest impact on patient care and keeps staff interested’. When describing their experiences in relation to formal CPD, respondents commonly emphasised that relevance of content was a key issue. Existing courses and study days were quite heavily criticised on the grounds that content was insufficiently related to practice, with methods of assessment not appropriate to meet practitioner need. In a few cases language was reported as a barrier to effective CPD, reflecting the relatively high proportion of overseas nurses in the London area (Buchan et al., 2003) whose first language may not be English. In the case of university courses assessment frequently involved writing essays and assignments. Some respondents suggested that nursing has become obsessed with the need to accredit learning and used this to argue the case for more skills-based courses and renewed emphasis on work-based learning. A few respondents expressed a view that ‘nursing has lost its way’ by becoming overly academic. They called for a return to traditional values, when much greater importance was placed on clinical experience: ‘Nurses seem to attend more and more courses yet have less clinical awareness. They are failed by an establishment that does not promote good clinical training’. There was a view that CPD should be a continuum throughout practice. Respondents distinguished between the needs of junior and more senior staff. Novice nurses were seen to require opportunities to develop and refine their skills. Once competency had been achieved, increasing length of practice was associated with the need to update skills and keep abreast of new develop-
Nurses’ experiences of continuing professional development ments. Expansion of the nursing role was associated with a need to provide new and additional opportunities to increase the individual’s repertoire of skills and allow them to diversify and develop personally as well as professionally. A few very senior and highly specialist nurses had reached a clinical ‘glass ceiling’. They claimed a lack of formal study days and courses to meet their needs. Instead they relied on self-directed study and events intended primarily for a medical audience.
607
clinical environment, able to promote effective learning opportunities during routine clinical practice. One respondent commented on the important role played by clinical tutors relating theory to practice and promoting an effective clinical learning environment, but no references were made about the contribution of university staff providing a good student experience.
Discussion Managing work, life and doing continuing professional development The demands of undertaking CPD conflicted with home and domestic commitments and were perceived as a barrier to achieving desirable work-life balance. Issues raised included the amount of time needed to travel to venues where study events were delivered, arranging child care and problems accessing libraries and computing facilities outside working hours. However, the area singled out for the most frequent and bitter criticism was the amount of their own time which individuals felt they were expected to contribute towards CPD, especially completing assignments: ‘I don’t think annual leave should be used as study time. It’s for having a break from nursing. Other professionals don’t have to use it for this’. They complained of expectation from managers that they would invest personal time in CPD intended primarily to improve service delivery. This resulted in considerable resentment, especially when individuals were already feeling the effects of heavy clinical workload, poor staffing and rapid pace of change in the NHS.
Making the best of continuing professional development Managers were considered to play a major role effecting uptake and use of CPD. ‘Good managers’ were identified as those who encouraged staff to undertake study days and courses, providing these were appropriate with equitable access. Once undertaken, CPD was perceived to have the capacity to enhance service delivery through the efforts of the individual and through a cascading effect allowing new knowledge and skills to reach other staff. However, these potential effects were seen to be curtailed by the ability and willingness of managers to ‘allow’ CPD to be implemented and cascaded. Good managerial style was also equated with the ability to create a supportive atmosphere in the
Caution should be exercised when interpreting these findings. The data reflect the views of nurses in only three NHS trusts, all in the same geographical locality, collected as part of a survey which had not been designed primarily to explore nurses’ experiences of CPD. However, response rate was good (Bowling, 2001) and of the 451 who returned questionnaires, over a quarter provided detailed information. This was unexpected and suggests that respondents felt strongly about the issues they raised. The findings cannot be generalised to the whole population of nurses, but are likely to be a fair reflection of the views of those who added comments. It is feasible that the high level and detailed nature of the responses were attained because the nurses felt a need to voice concerns to researchers taking a neutral stance. They may have been more cautious in formal course evaluations which would be read by managers and education providers. Many of the opinions expressed corroborate the findings of other studies. Poor staffing levels and absence of colleagues to provide ‘backfill’ was the same problem as in earlier reports (Shields, 2002) and as in the study by Gould et al., 2004b), there was a feeling from some respondents that longer courses with academic emphasis were being promoted at the expense of those intended primarily to attain competency in clinical skills. It was also clear that for many nurses, work-based learning was still an important way of learning (Birchenell, 1999), and as in previous studies the managerial style of ward sisters was key to providing an effective clinical learning environment (Cameron-Buccheri and Ogier, 1994). Part-time staff, those working exclusively at night or the weekend and nearing retirement still perceived themselves to be disadvantaged, corroborating earlier findings (Larcombe and Maggs, 1991; Barriball and While, 1996; Watson et al., 2003). A number of new findings emerged from the data. Unlike managers and education providers (Furze and Pearcey, 1999; Lawton and Wimpenny, 2003; Gould et al., 2004a), practitioners were clear about the purpose of CPD. They identified it as
608 important to maintain the safety of patients and staff, a means of improving service provision and of promoting career and personal progression. The role of CPD in personal development was linked to respondents’ awareness of current shortfalls in nursing numbers (Buchan and Seccombe, 2004). Rewarding staff with appropriate CPD was identified as a way of boosting staff morale and promoting retention. Practitioners regarded CPD as a continuum throughout the career of the individual, thus concurring with government policy in the UK (Spouse, 2001). However, they recognised that individuals’ needs would change according to stage in career trajectory. Some women with young families remain in the workforce through necessity rather than choice when their children are very young. Excessive demands from CPD may contribute to the unattractiveness of nursing work instead of being one of the major rewards and a key driver encouraging retention (Shields and Ward, 2001). This does not mean that the same individual would not welcome more challenging work with renewed emphasis on CPD at a later date. Practitioners at the same stage in their career may also see things differently. One respondent in her fifties expressed a clear preference for greater access to CPD to enhance professional and personal development, while another of the same age wanted CPD aimed at professional updating only. Although nearly all respondents were positive about the benefits of life long learning, their comments indicated that pursuing CPD may have unintended consequences which can be negative for the individual. Many felt pressurised by managers into undertaking CPD to meet service requirements. This was a source of resentment, especially when lengthy assignments had to be completed in respondents’ own time. As in the studies by Ellis and Nolan (2005) and Hughes (2005), managers played a key role permitting or withholding desirable CPD and their management style was considered to play an important role in the individual’s ability to implement new skills and knowledge. No mention was made about the role of university staff despite their potential for working in a pastoral role with mature students (Johnson and Copnell, 2002) and their responsibility to promote study skills, especially for students lacking recent experience of academic work (Mansell et al., 2002).
Conclusion Nurses could distinguish between CPD intended to improve career and personal development and
D. Gould et al. CPD intended to update knowledge and skills. Positive comments were tempered with a belief that too many demands placed on the individual encroach unacceptably on life outside work. Resentment was experienced when lengthy assignments had to be completed in the individual’s own time, CPD was not considered relevant, access was denied to study events that were especially desirable or opportunities to implement new knowledge and skills were curtailed. Managers were regarded as pivotal in ensuring effective access and use of CPD. However, university staff were apparently not perceived to make any difference to the experience of undertaking CPD. Health policy in the UK is built on the assumption that nurses’ roles can be extended through CPD and that CPD is a key factor aiding nursing retention. Thus these findings are potentially important and should also be explored with a larger, more representative sample. The role of university staff in relation to CPD should be explored in greater depth.
Acknowledgements Financial support for this study was provided by the General Nursing Council Trust for England and Wales.
References Barriball, K.L., While, A.E., 1996. Participation in continuing professional education in nursing: findings of an interview study. J. Adv. Nurs. 23, 999–1007. Birchenell, P., 1999. Editorial. Developing a work-based learning philosophy. Nurs. Educ. Today 19, 173–174. Bowling, A., 2001. Research methods in health: investigating health and health services. Open University Press, Buckingham. Buchan, J., Finlayson, B., Gough, P., 2003. In capital health. King’s Fund, London. Buchan, J., Seccombe, I., 2004. Fragile future? A review of the UK nursing labour market in 2003Royal College of Nursing Labour Market Review. RCN, London. Cameron-Buccheri, R., Ogier, M.E., 1994. The USA’s nurse managers and the UK’s ward sisters: critical roles for empowerment. J. Clin. Nurs. 3, 205–212. Delamont, S., 1992. Fieldwork in Educational Settings: Methods, Pitfalls and Perspectives. Falmer, London. Department of Health, 1998. Quality in the NHS. A first class service. Stationary Office. London. Department of Health, 1999. Making a Difference. Stationary Office, London. Department of Health, 2000. The NHS Plan. A Plan for Investment, a Plan for Reform. Stationary Office. London. Department of Health, 2001. Working Together, Learning Together. A framework for lifelong learning in the NHS. Stationary Office. London.
Nurses’ experiences of continuing professional development Department of Health, 2003. The NHS knowledge and skills framework and related development review: summary. Available from. Ellis, E., Nolan, M., 2005. Illuminating continuing professional education: unpacking the black box. Int. J. Nurs. Stud. 42, 97–106. Friedman, A., Phillips, M., 2004. Continuing professional development: developing a vision. J. Educ. Work 17, 361–376. Furze, G., Pearcey, P., 1999. Continuing education in nursing: a review of the literature. J. Adv. Nurs. 29, 355–363. Glacklin, M., 1998. Investigation into experiences of older students undertaking a pre-registration diploma in nursing course. Nurs. Educ. Today 18, 576–582. Gould, D.J., Kelly, D., White, I., Chidgey, J., 2004a. Training needs analysis: a literature review and reappraisal. Int. J. Nurs. Stud. 41, 471–486. Gould, D.J., Kelly, D., White, I., Glen, S., 2004b. The impact of commissioning processes on the delivery of continuing professional education for cancer and palliative care. Nurs. Educ. Today 24, 443–451. Hicks, C., Hennessy, D., 1997. Identifying training objectives: the role of negotiation. J. Nurs. Management 5 (5), 263–265. Hughes, E., 2005. Nurses’ perceptions of continuing professional development. Nurs. Standard 19 (43), 41–49. Johnson, A., Copnell, B., 2002. Benefits and barriers for registered nurses undertaking post-graduate diplomas in paediatric nursing. Nurs. Educ. Today 22, 118–127. Kevern, J., Webb, C., 2005. Mature women’s experiences of preregistration nurse education. J. Adv. Nurs. 45, 297– 306. Lader, D., 1995. Qualified Nurses, Midwives and Health Visitors. A Survey Carried out by the Social Survey Division of the Office of Population and Censuses on behalf of the Department of Health. HMSO. London. Larcombe, K., Maggs, C., 1991. Processes for Identifying the Continuing Professional Education needs of Nurses, Midwives and Health Visitors. An Evaluation. English National Board for Nurses, Midwives and Health Visitors, London.
609
Lawton, S., Wimpenny, P., 2003. Continuing professional development: a review. Nurs. Standard 17 (24), 41–44. Majomi, P., Brown, B., Crawford, P., 2003. Sacrificing the personal to the professional: community mental health nurses. J. Adv. Nurs. 42, 527–538. Mansell, I., Bennett, G., Torrance, C., Fairbairn, G., 2002. The role of the nurse lecturer in the supervision of students’ essays, projects and assignments: results of an all Wales questionnaire survey. Nurs. Educ. Today 22, 511–517. Miles, M.B., Huberman, A.M., 1994. Qualitative data analysis: an expanded source book. Second ed. Sage, Thousand Oaks, CA. Matthews-Smith, G., Obserski, I., Gray, M., Carter, D., Smith, L., 2001. A new module in caring for older adults: problembased learning and practice portfolios. J. Nurs. Educ. 40 (2), 73–78. National Audit Commission 2001. Hidden talents. Education, Training and Development for Healthcare Staff in NHS Trusts. Audit Commission. London. Pascall, G., Cox, R., 1993. Women Returning to Higher Education. Open University Press, Buckingham. Shields, P., 2002. Commissioning post-registration education programmes for health care professionals. Nurs. Educ. Today 22, 285–292. Shields, M.A., Ward, M., 2001. Improving nurse retention in the NHS in England. The impact of job satisfaction on intentions to quit. J. Health Econ. 20, 677–701. Smith, J., Topping, A., 2001. Unpacking the ’value added’ impact of continuing professional education: a multi– method case study approach. Nurs. Educ. Today 21, 341– 349. Spouse, J., 2001. Work-based learning in health care environments. Nurs. Educ. Pract. 1, 12–18. Tovey, E.J., Adams, A., 1999. The changing nature of nurses’ job satisfaction: an exploration of sources of satisfaction in the 1990s. J. Adv. Nurs. 30, 150–160. Watson, R., Manthorpe, J., Andrews, J., 2003. Nurses Over Fifty: Options, Decisions and Outcomes. James Rowntree Foundation. London.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Nurses’ experiences of continuing professional development Dinah Gould *, Nicholas Drey, Emma-Jane Berridge St Bartholomew’s School of Nursing and Midwifery, 20 Street Bartholomew’s Close, City University, London EC1 A7QN, United Kingdom Accepted 29 August 2006
KEYWORDS
Summary Continuing professional development is regarded as part of the nursing role in the National Health Service. Health policy in the United Kingdom is built on the assumption that nurses’ roles can be extended through continuing professional development which is also considered to be a key factor in nursing retention. Previous research has considered the provision of learning mainly from the perspective of managers and education providers. The purpose of this paper is to explore nurses’ experiences of continuing professional development. The results presented in this paper form part of a larger survey (n = 451, response rate = 64.9%) designed to examine opportunities for continuing professional development and factors encouraging and discouraging uptake. An unexpectedly high number of respondents (n = 125, 27.7%) commented extensively on their personal experiences of continuing professional development. These comments were analysed inductively. Five main themes emerged: who and what is continuing professional development for?; accessing continuing professional development; one size does not fit all; managing work, life and doing continuing professional development; and making the best of continuing professional development. Most responses were positive, but the demands of taking courses were perceived to encroach on life outside work, especially the need to complete lengthy assignments. Managers were perceived to operate as the gatekeepers to course admission and opportunities to implement new knowledge and expertise. No comments were received concerning the role of education staff in continuing professional development. c 2006 Elsevier Ltd. All rights reserved.
Post-registration nursing education; Continuing professional development
Introduction * Corresponding author. Tel.: +44 0207 040 5449; fax: +44 0207 040 8888. E-mail address: [email protected] (D. Gould).
In the National Health Service (NHS) the Agenda for Change reforms have linked nurses’ pay and progression to their ability to demonstrate advance-
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.08.021
Nurses’ experiences of continuing professional development ments in clinical expertise and knowledge (Department of Health, 2003). Thus continuing professional development (CPD) has become an explicit part of the nursing role. Much has been written about CPD from the perspective of managers and nurse educators (Furze and Pearcey, 1999; Lawton and Wimpenny, 2003; Gould et al., 2004a), but accounts of qualified nurses’ experiences are poorly represented. Numerous studies include student evaluations, but are limited because they obtain information about the merits of the course from a managerial, educational and occasionally service user perspective (see for example Matthews-Smith et al., 2001; Smith and Topping, 2001). Recently Ellis and Nolan (2005) have made a valuable attempt to fill this gap. Their in-depth qualitative study illustrates the role played by managers deciding who should undertake CPD and providing opportunities to implement newly acquired expertise on return to clinical practice. The drawback of this study is that it is small scale, reflecting the opinions of only a select number of nurses in relation to a single course. The results of a questionnaire study by Hughes (2005), although obtaining data from 200 staff, obtained detailed information from only eight people. The purpose of this paper is to explore nurses’ experiences of continuing professional development. The results presented in this paper form part of a larger survey (n = 451, response rate = 64.9%) designed to examine opportunities for continuing professional development and factors encouraging and discouraging uptake. An unexpectedly high number of respondents (n = 125, 27.7%) commented extensively on their personal experiences of continuing professional development. These comments were analysed inductively. The main survey findings are discussed elsewhere.
Literature review CPD is considered essential for all health workers in the NHS Plan (Department of Health, 2000) and numerous other government documents (see for example Department of Health, 1998; Department of Health, 1999; Department of Health, 2001; National Audit Commission, 2001) because of its importance in the delivery of safe and effective care and its supposed role in securing job satisfaction and reduced attrition (Department of Health, 2003). This belief has been strengthened by research demonstrating links between job satisfaction with opportunities to undertake CPD (Tovey
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and Adams, 1999) and nursing retention (Shields and Ward, 2001). There are concerns that opportunities to undertake CPD are reduced for nurses working exclusively at night, part-time (Larcombe and Maggs, 1991; Barriball and While, 1996) and for those approaching retirement (Watson et al., 2003), thus placing them at disadvantage. A different view has been taken by Friedman and Phillips (2004) who point out that although widely promoted by professional bodies throughout the United Kingdom (UK) and by the government, CPD is in fact poorly defined, with confusion about its purpose in both the academic and practitioner literature, especially in relation to nursing. This is reflected in reviews of the literature (Furze and Pearcey, 1999; Lawton and Wimpenny, 2003; Gould et al., 2004a) which suggest ambivalence on the part of managers and educators concerning whether CPD is intended primarily to increase service provision by increasing the range and repertoire of nursing skills or has a role in career and personal progression. There are reports of resentment among nurses who perceive that their personal needs are becoming overlooked by those of the service (Hicks and Hennessy, 1997) and some indication that heavy workload and absence of colleagues to cover the work (‘backfill’) prevent uptake of CPD (Shields, 2002). A recent qualitative study exploring the commissioning process also suggests that longer courses with academic emphasis are being promoted at the expense of those intended primarily to promote clinical expertise (Gould et al., 2004b). In this study university staff discussed the challenges of supporting post-registration students with inadequate study skills and the difficulty of making some types of course and assessment methods appear relevant to clinical work. This finding ties in with the findings of a growing body of literature suggesting that mature students in higher education have special needs which must be met by academic staff to enable them to perform well (Pascall and Cox, 1993). Mature pre-registration nursing students experience additional problems because of the physically and emotionally demanding nature of clinical placements and the need to travel to different venues (Glacklin and Glacklin, 1998; Kevern and Webb, 2005). In contrast little has been written about the challenges faced by qualified nurses undertaking CPD despite a requirement to engage in life long study and professional updating. This omission is surprising given the well documented problems encountered by working nurses with young families, the impact this is believed to have on the retention of experienced practitioners (Lader, 1995; Buchan and Seccombe, 2004) and the
604 tensions experienced when attempting to balance the demands of work and home life (Majomi et al., 2003).
The study Aim The aim of this part of the study was to explore qualified nurses’ experiences of CPD.
Study design The main study was undertaken with nurses (grade D-I) employed in three acute NHS trusts in London. Questionnaires were distributed via the internal hospital post to a random 10% sample of eligible nurses identified from the payroll. Each questionnaire was coded to preserve the anonymity of the respondent while allowing the research team to identify non-returns. Three reminders were sent. Completed questionnaires and consent forms were returned in sealed envelopes. Respondents were asked to state which long and short courses, study days and other learning opportunities they had received during the last twelve months. An open question at the end of the survey instrument invited comments. Of the 695 questionnaires dispatched, 451 (64.9 %) were returned and all were fully completed and usable. One hundred and twenty five (27.7%) provided detailed comments in response to the open question.
Ethical considerations Permission to undertake the study was granted by the multi-regional ethics committee serving the NHS trusts. All respondents were assured that the data would be treated in strict confidence and their identity as well as the identity of their institutions would not be disclosed in the final report or publications. All respondents received written information about the project. A consent form was included with the questionnaire and returned in the same envelope.
Analysis of the qualitative data The researchers read and reread each response to the open question independently to develop an overall impression of the data. They then worked together to code the content of each response. Significant ‘units of meaning’ (phrases, sentences, paragraphs) were highlighted, and interpretative
D. Gould et al. codes created (Miles and Huberman, 1994). The main themes emerging from each response were identified by bringing these codes into provisional relational groupings. Once each response had been examined and coded, it was possible to bring emergent themes from all the responses together into broader, over-arching categories. In a subsequent exercise, the responses were read and reread to explore and refine these tentative categories. Patterns, themes and regularities were sought, as well as contrasts, paradoxes and irregularities (Delamont, 1992). Through discussion between the researchers, categories were added and merged and interpretations refined to allow similarities and divergences of opinion to be noted and discussed. Analysis of the quantitative data and presentation of these findings are beyond the scope of this paper.
Findings Table 1 shows the characteristics of the sample overall. As expected, most respondents were women (n = 384, 85.1%). The majority (n = 292, 65.2%) were under forty years of age: very few nurses were under 25 (n = 29, 6.4%) or over 50 (n = 43, 9.5%). Over half the sample described themselves as White Caucasian (n = 245, 54.3%); 91 (20.2%) described themselves as Black; 68 (15.1%) described themselves as Asian; and 43 (9.5%) placed themselves in none of these categories. Four nurses did not reveal their ethnicity. A third were educated to degree level (n = 149, 33.0%) and a few to masters level (n = 36, 8.0%). Less than half (n = 206, 46.8%) had been qualified for more than 12 years. However, most (n = 284, 63%) had worked in their current trust for at least three years and a third were employed in senior grades (G,H and I). Most were employed fulltime (n = 392, 87.9%). Response rate was similar across all there trusts. Very few comments reflected completely negative opinions about CPD, but the majority of respondents indicated that although important for the sake of the service and the individual, pursuing CPD may have unintended consequences, some of which can be negative. Five main themes emerged from the data:
Who and what is CPD for? Accessing CPD. One size does not fit all. Managing work, life and doing CPD. Making the best of CPD.
Nurses’ experiences of continuing professional development Table 1
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Characteristic of the sample
Variable
Trust 1 N (%)
Trust 2 N (%)
Trust 3 N (%)
All N (%)
Gender Male Female
17 (14.2) 103 (85.8)
13 (10.6) 108 (87.8)
32 (15.4) 173 (83.2)
62 (13.7) 384 (85.1)
Age* 21–25 26–30 31–40 41–50 >50
6 (5.0) 16 (13.3) 51 (42.5) 39 (32.5) 8 (6.7)
4 (3.3) 14 (11.4) 58 (47.2) 34 (27.6) 12 (9.8)
19 (9.1) 44 (21.2) 80 (38.5) 40 (19.2) 23 (11.1)
Ethnicity* Asian Black Other White
8 (6.7) 24 (20.0) 11 (9.2) 76 (63.3)
23 43 12 44
Education (highest level)* Registered Nurse (Diploma) Degree Masters*
72 (60.0) 30 (25.0) 18 (15.0)
87 (70.7) 31 (25.2) 5 (4.1)
122 (58.7) 73 (35.1) 13 (6.3)
Time Qualified (yrs)* Median (IQR)
13 (11.00)
13 (12.25)
10 (15)
12 (13)
Time employed by trust <6 mths 6 to 12 mths 1–2 yrs 3–5 yrs >5 yrs
7 (5.8) 9 (7.5) 23 (19.2) 30 (25.0) 51 (42.5)
6 (4.9) 19 (15.6) 24 (19.7) 35 (28.7) 38 (31.1)
3 (1.4) 21 (10.1) 53 (25.6) 63 (30.4) 67 (32.4)
16 49 100 128 156
(3.6) (10.9) (22.3) (28.5) (34.7)
Grade* D E F G H I
14 (11.7) 15 (12.5) 22 (18.3) 31 (25.8) 30 (25.0) 8 (6.7)
18 (14.8) 34 (27.9) 29 (23.8) 23 (18.9) 14 (11.5) 4 (3.3)
44 (21.3) 66 (31.9) 43 (20.8) 35 (16.9) 17 (8.2) 2 (1.0)
76 115 94 89 61 14
(16.9) (25.6) (20.9) (19.8) (13.6) (3.1)
106 (89.8) 12 (10.2)
107 (87.0) 16 (13.0)
179 (87.3) 26 (12.7)
Hours Full-time Part-time *
(18.7) (35.0) (9.8) (35.8)
37 24 20 125
(17.8) (11.5) (9.6) (60.1)
29 74 189 113 43
(6.4) (16.4) (41.9) (25.1) (9.5)
68 91 43 245
(15.1) (20.2) (9.5) (54.3)
281 (62.3) 134 (29.7) 36 (8.0)
392 (87.9) 54 (12.1)
Significant differences between the trusts.
Who and what is CPD for? Respondents thought that CPD plays an important role in enhancing service provision and maintaining safety for patients and nurses: ‘CPD helps nurses keep up to date and avoid mistakes which put patients at risk’. Links were made between CPD and clinical governance and the role of CPD bridging the theorypractice gap. The importance of maintaining skills and remaining professionally updated was ex-
pressed explicitly by some nurses and was implicit in the comments offered by others. CPE was also considered to play a key role in career and personal development: ‘CPD is vitally important to me personally and professionally and benefits both’. A number of respondents dwelt on the need for staff to feel ‘valued’ and ‘motivated’ through opportunities to undertake CPD. This was closely related to awareness of the need to improve retention, especially of experienced nurses.
606
Accessing continuing professional development Providing study leave has important and well documented resource implications for managers in the NHS (Gould et al., 2004b). These were all reflected in the comments offered by respondents in this study. There were reports of not being able to undertake CPD through lack of staff to fill the gap in the workforce; course cancellation by education providers through lack of uptake by other practitioners; a dearth of places on courses in high demand, especially those with the potential to enhance career progression; and difficulties of access experienced by particular groups including: part-time nurses; those working exclusively at night and the weekend; and those nearing retirement. A number of new reasons for poor access also emerged. There was some perception that opportunity to undertake CPD formed an important part of organisational propaganda promulgated by managers in the drive to attract nurses to the trusts. Once they joined the workforce, some respondents concluded that ‘lip service’ was paid to course applications. This became a powerful source of resentment in some cases: ‘Nurses need to be supported and valued for their efforts or they will leave . . . I thought I would be happy in this trust, but the policies (for CPD) don’t apply in reality . . . they are only good in writing’. Inequality of one form or another was also reported as a barrier to accessing CPD. There were sporadic examples of failure to access training events because managers were not supportive to the individual. In a few instances respondents suggested that managers denied access because they would be threatened by the superior knowledge that subordinates would gain. Implicit in this suggestion is that CPD has the potential to be used as a management tool with the capacity to reward or penalise individuals. ‘Education is often used as a stick to beat staff . . . managers control access to courses. Career promotion is used to keep staff in line’. Some respondents holding the post of sister or charge nurse attributed lack of opportunity to the indispensable nature of their role as lynchpin running the ward or department. Whether this was seen as a bad thing or just an inevitable consequence of occupying such a key role was not entirely apparent: ‘I always put my staff first for training opportunities as I am the most senior. It means I’m often behind them in terms of the latest information. I can’t go on courses – I have to supervise the ward’.
D. Gould et al. A few respondents reported that the university application procedure was lengthy and bureaucratic, operating as a disincentive to future course applications.
One size does not fit all This theme related to perceptions that the most effective mode of delivery depends on the type of learning opportunity that the CPD is intended to offer. Classroom-based courses might meet the needs of one type of learning or the preferences of a given individual, but would not be the most effective or preferred approach of others. Workbased learning was regarded by many nurses as at least as important as classroom-based opportunities. Some respondents felt that it no longer received the emphasis it should, with missed opportunities for staff development: ‘I feel on the job learning . . . has the greatest impact on patient care and keeps staff interested’. When describing their experiences in relation to formal CPD, respondents commonly emphasised that relevance of content was a key issue. Existing courses and study days were quite heavily criticised on the grounds that content was insufficiently related to practice, with methods of assessment not appropriate to meet practitioner need. In a few cases language was reported as a barrier to effective CPD, reflecting the relatively high proportion of overseas nurses in the London area (Buchan et al., 2003) whose first language may not be English. In the case of university courses assessment frequently involved writing essays and assignments. Some respondents suggested that nursing has become obsessed with the need to accredit learning and used this to argue the case for more skills-based courses and renewed emphasis on work-based learning. A few respondents expressed a view that ‘nursing has lost its way’ by becoming overly academic. They called for a return to traditional values, when much greater importance was placed on clinical experience: ‘Nurses seem to attend more and more courses yet have less clinical awareness. They are failed by an establishment that does not promote good clinical training’. There was a view that CPD should be a continuum throughout practice. Respondents distinguished between the needs of junior and more senior staff. Novice nurses were seen to require opportunities to develop and refine their skills. Once competency had been achieved, increasing length of practice was associated with the need to update skills and keep abreast of new develop-
Nurses’ experiences of continuing professional development ments. Expansion of the nursing role was associated with a need to provide new and additional opportunities to increase the individual’s repertoire of skills and allow them to diversify and develop personally as well as professionally. A few very senior and highly specialist nurses had reached a clinical ‘glass ceiling’. They claimed a lack of formal study days and courses to meet their needs. Instead they relied on self-directed study and events intended primarily for a medical audience.
607
clinical environment, able to promote effective learning opportunities during routine clinical practice. One respondent commented on the important role played by clinical tutors relating theory to practice and promoting an effective clinical learning environment, but no references were made about the contribution of university staff providing a good student experience.
Discussion Managing work, life and doing continuing professional development The demands of undertaking CPD conflicted with home and domestic commitments and were perceived as a barrier to achieving desirable work-life balance. Issues raised included the amount of time needed to travel to venues where study events were delivered, arranging child care and problems accessing libraries and computing facilities outside working hours. However, the area singled out for the most frequent and bitter criticism was the amount of their own time which individuals felt they were expected to contribute towards CPD, especially completing assignments: ‘I don’t think annual leave should be used as study time. It’s for having a break from nursing. Other professionals don’t have to use it for this’. They complained of expectation from managers that they would invest personal time in CPD intended primarily to improve service delivery. This resulted in considerable resentment, especially when individuals were already feeling the effects of heavy clinical workload, poor staffing and rapid pace of change in the NHS.
Making the best of continuing professional development Managers were considered to play a major role effecting uptake and use of CPD. ‘Good managers’ were identified as those who encouraged staff to undertake study days and courses, providing these were appropriate with equitable access. Once undertaken, CPD was perceived to have the capacity to enhance service delivery through the efforts of the individual and through a cascading effect allowing new knowledge and skills to reach other staff. However, these potential effects were seen to be curtailed by the ability and willingness of managers to ‘allow’ CPD to be implemented and cascaded. Good managerial style was also equated with the ability to create a supportive atmosphere in the
Caution should be exercised when interpreting these findings. The data reflect the views of nurses in only three NHS trusts, all in the same geographical locality, collected as part of a survey which had not been designed primarily to explore nurses’ experiences of CPD. However, response rate was good (Bowling, 2001) and of the 451 who returned questionnaires, over a quarter provided detailed information. This was unexpected and suggests that respondents felt strongly about the issues they raised. The findings cannot be generalised to the whole population of nurses, but are likely to be a fair reflection of the views of those who added comments. It is feasible that the high level and detailed nature of the responses were attained because the nurses felt a need to voice concerns to researchers taking a neutral stance. They may have been more cautious in formal course evaluations which would be read by managers and education providers. Many of the opinions expressed corroborate the findings of other studies. Poor staffing levels and absence of colleagues to provide ‘backfill’ was the same problem as in earlier reports (Shields, 2002) and as in the study by Gould et al., 2004b), there was a feeling from some respondents that longer courses with academic emphasis were being promoted at the expense of those intended primarily to attain competency in clinical skills. It was also clear that for many nurses, work-based learning was still an important way of learning (Birchenell, 1999), and as in previous studies the managerial style of ward sisters was key to providing an effective clinical learning environment (Cameron-Buccheri and Ogier, 1994). Part-time staff, those working exclusively at night or the weekend and nearing retirement still perceived themselves to be disadvantaged, corroborating earlier findings (Larcombe and Maggs, 1991; Barriball and While, 1996; Watson et al., 2003). A number of new findings emerged from the data. Unlike managers and education providers (Furze and Pearcey, 1999; Lawton and Wimpenny, 2003; Gould et al., 2004a), practitioners were clear about the purpose of CPD. They identified it as
608 important to maintain the safety of patients and staff, a means of improving service provision and of promoting career and personal progression. The role of CPD in personal development was linked to respondents’ awareness of current shortfalls in nursing numbers (Buchan and Seccombe, 2004). Rewarding staff with appropriate CPD was identified as a way of boosting staff morale and promoting retention. Practitioners regarded CPD as a continuum throughout the career of the individual, thus concurring with government policy in the UK (Spouse, 2001). However, they recognised that individuals’ needs would change according to stage in career trajectory. Some women with young families remain in the workforce through necessity rather than choice when their children are very young. Excessive demands from CPD may contribute to the unattractiveness of nursing work instead of being one of the major rewards and a key driver encouraging retention (Shields and Ward, 2001). This does not mean that the same individual would not welcome more challenging work with renewed emphasis on CPD at a later date. Practitioners at the same stage in their career may also see things differently. One respondent in her fifties expressed a clear preference for greater access to CPD to enhance professional and personal development, while another of the same age wanted CPD aimed at professional updating only. Although nearly all respondents were positive about the benefits of life long learning, their comments indicated that pursuing CPD may have unintended consequences which can be negative for the individual. Many felt pressurised by managers into undertaking CPD to meet service requirements. This was a source of resentment, especially when lengthy assignments had to be completed in respondents’ own time. As in the studies by Ellis and Nolan (2005) and Hughes (2005), managers played a key role permitting or withholding desirable CPD and their management style was considered to play an important role in the individual’s ability to implement new skills and knowledge. No mention was made about the role of university staff despite their potential for working in a pastoral role with mature students (Johnson and Copnell, 2002) and their responsibility to promote study skills, especially for students lacking recent experience of academic work (Mansell et al., 2002).
Conclusion Nurses could distinguish between CPD intended to improve career and personal development and
D. Gould et al. CPD intended to update knowledge and skills. Positive comments were tempered with a belief that too many demands placed on the individual encroach unacceptably on life outside work. Resentment was experienced when lengthy assignments had to be completed in the individual’s own time, CPD was not considered relevant, access was denied to study events that were especially desirable or opportunities to implement new knowledge and skills were curtailed. Managers were regarded as pivotal in ensuring effective access and use of CPD. However, university staff were apparently not perceived to make any difference to the experience of undertaking CPD. Health policy in the UK is built on the assumption that nurses’ roles can be extended through CPD and that CPD is a key factor aiding nursing retention. Thus these findings are potentially important and should also be explored with a larger, more representative sample. The role of university staff in relation to CPD should be explored in greater depth.
Acknowledgements Financial support for this study was provided by the General Nursing Council Trust for England and Wales.
References Barriball, K.L., While, A.E., 1996. Participation in continuing professional education in nursing: findings of an interview study. J. Adv. Nurs. 23, 999–1007. Birchenell, P., 1999. Editorial. Developing a work-based learning philosophy. Nurs. Educ. Today 19, 173–174. Bowling, A., 2001. Research methods in health: investigating health and health services. Open University Press, Buckingham. Buchan, J., Finlayson, B., Gough, P., 2003. In capital health. King’s Fund, London. Buchan, J., Seccombe, I., 2004. Fragile future? A review of the UK nursing labour market in 2003Royal College of Nursing Labour Market Review. RCN, London. Cameron-Buccheri, R., Ogier, M.E., 1994. The USA’s nurse managers and the UK’s ward sisters: critical roles for empowerment. J. Clin. Nurs. 3, 205–212. Delamont, S., 1992. Fieldwork in Educational Settings: Methods, Pitfalls and Perspectives. Falmer, London. Department of Health, 1998. Quality in the NHS. A first class service. Stationary Office. London. Department of Health, 1999. Making a Difference. Stationary Office, London. Department of Health, 2000. The NHS Plan. A Plan for Investment, a Plan for Reform. Stationary Office. London. Department of Health, 2001. Working Together, Learning Together. A framework for lifelong learning in the NHS. Stationary Office. London.
Nurses’ experiences of continuing professional development Department of Health, 2003. The NHS knowledge and skills framework and related development review: summary. Available from
609
Lawton, S., Wimpenny, P., 2003. Continuing professional development: a review. Nurs. Standard 17 (24), 41–44. Majomi, P., Brown, B., Crawford, P., 2003. Sacrificing the personal to the professional: community mental health nurses. J. Adv. Nurs. 42, 527–538. Mansell, I., Bennett, G., Torrance, C., Fairbairn, G., 2002. The role of the nurse lecturer in the supervision of students’ essays, projects and assignments: results of an all Wales questionnaire survey. Nurs. Educ. Today 22, 511–517. Miles, M.B., Huberman, A.M., 1994. Qualitative data analysis: an expanded source book. Second ed. Sage, Thousand Oaks, CA. Matthews-Smith, G., Obserski, I., Gray, M., Carter, D., Smith, L., 2001. A new module in caring for older adults: problembased learning and practice portfolios. J. Nurs. Educ. 40 (2), 73–78. National Audit Commission 2001. Hidden talents. Education, Training and Development for Healthcare Staff in NHS Trusts. Audit Commission. London. Pascall, G., Cox, R., 1993. Women Returning to Higher Education. Open University Press, Buckingham. Shields, P., 2002. Commissioning post-registration education programmes for health care professionals. Nurs. Educ. Today 22, 285–292. Shields, M.A., Ward, M., 2001. Improving nurse retention in the NHS in England. The impact of job satisfaction on intentions to quit. J. Health Econ. 20, 677–701. Smith, J., Topping, A., 2001. Unpacking the ’value added’ impact of continuing professional education: a multi– method case study approach. Nurs. Educ. Today 21, 341– 349. Spouse, J., 2001. Work-based learning in health care environments. Nurs. Educ. Pract. 1, 12–18. Tovey, E.J., Adams, A., 1999. The changing nature of nurses’ job satisfaction: an exploration of sources of satisfaction in the 1990s. J. Adv. Nurs. 30, 150–160. Watson, R., Manthorpe, J., Andrews, J., 2003. Nurses Over Fifty: Options, Decisions and Outcomes. James Rowntree Foundation. London.