Perceptions of registered nurses in four state health insititutions on continuing formal education

Curationis 33 (2): 41-50 This study investigated registered nurses in four selected state health institutions’ perceptions with regard to continuing formal education. The relevance of continuing formal education is being emphasised globally by the increasing quest for quality assurance and quality management systems within an ethos of continuous improve­ ment. According to Tlholoe (2006:5), it is important to be committed to continual learning, as people’s knowledge become less relevant because skills gained early in a career are insufficient to avoid costly mistakes made through ignorance. Continu­ ing formal education in nursing is a key element to the maintenance of quality in health care delivery. The study described: • registered nurses’ views on continuing formal education • registered nurses’ perceived barriers to continuing formal education A quantitative descriptive survey design was chosen using a questionnaire for data collection. The sample consisted of 40 registered nurses working at four state health institutions in the Western Cape Province, South Africa. Convenience sampling was selected to include registered nurses who were on duty on the days during which the researcher visited the health institutions to distribute the questionnaires. The ques­ tionnaire contained mainly closed-ended and a few open-ended questions. Content validity of the instrument was ensured by doing a thorough literature review before construction of items and a pretest. Reliability was established by the pretest and providing the same information to all respondents before completion of the question­ naires. The ethical considerations of informed consent, anonymity and confidential­ ity were adhered to and consent to conduct the study was obtained from relevant authorities. Descriptive statistics, based on calculations using the Microsoft (MS) Excel (for Windows 2000) programme, were used to summarise and describe the research results. The research results indicated that most registered nurses perceive continuing formal education as beneficial to their personal and professional growth and that it could lead towards improving the quality of patient/client care, but barriers exist which prevent or deter them from undertaking continuing formal education programmes. The main structural barriers included lack of funding and lack of coher­ ent staff development planning and physical barriers including job and family re­ sponsibilities. Tel: (012)429-6545 Fax:(012)429-6688 E-mail: potgie@unisa.ac.za


Introduction
The World Health Report emphasises the need for strategic planning with regard to continuing education for health care providers.Hum an re sources are the most important o f the health system's resource inputs.The performance o f health care systems ul timately depends on the knowledge, skills and motivation o f the people re sponsible for delivering services.Edu cation and training are key investment tools as old skills become obsolete with the advent of new technologies (World Health Organisation [WHO] 2000:76).
The relationship between societal and technical change and subsequent pres sures for reform in health care systems require nurses to constantly face in creasing demands to remain profes sionally up to date, competent and ca pable to cope with the stresses and challenges in the health care environ ment (Peck, McCall & Rotem 2000:432).
Professionalism relies increasingly on an ability to respond quickly to chang ing market conditions, to client require ments, and to the influence o f govern ment policies.Professionals are encour aged to embrace change and foster in novation.New skills essential to pro fessional and organisational success, are needed to adapt to these changes.
The professions are increasingly at much higher risk from legal claims of negligence than in the past.Health care professionals work in a very structured environment where regulation and ac countability for practice are required.
Nursing deals with complex human problems, and cannot limit itself to a circumscribed body o f information.In order to respond to the array o f prob lems that nurses confront, the profes sion as a whole and its members indi vidually must be encouraged to profit from every source o f know ledge (Eustace 2001:134;Page 2004:29)

Background and literature review
The nursing profession is accountable to society for providing high-quality care for patients and families.Nurses therefore have to maintain competen cies and keep up to date with the most recent research and developments in patient care.According to Smith and Topping (2001:342), professional con tinuing education empowers nurses to stay effective in their jobs and improve quality in health service delivery.
A review o f relevant literature revealed many studies which describe the ben efits of continuing formal education but several authors report that there are also barriers to continuing formal edu cation.

Benefits of continuing formal education
Effective continuing education has been linked with raised staff morale, in creased motivation and staff retention.and more sophisticated public.A con sequence of this trend is that the pub lic expect a higher duty of care and level of service from their professional advi sors than in the past.The skills ac quired during an initial training period may not equip new staff for this role.
Continuing formal education has impor tant implications for both professional nurses and for the general public.The public has a right to be safeguarded against malpractice, and they have an expectation that nurses will possess up-to-date knowledge and skills appro priate to the specialist field in which they practice (Ironside 2008:92).

Barriers to continuing formal education
While the literature points to the ben efits o f continuing formal education, there is an abundance o f literature which points to barriers to continuing formal nursing education.

Problem statement
In South Africa, nurses carry the bur den o f a public health system battling to overcome staff shortages, a grow ing HIV/AIDS pandemic and under resourced public health facilities which result in stressful working conditions.It is difficult to see beyond these harsh conditions to how attaining a higher nursing qualification will ease the bur den o f care and attract increased mon etary reward.The researcher who, at the time o f the study, was a facilitator for a post-registration nursing pro gramme, periodically conducted inter views with nurses who were battling to attend classes, complete assign ments and who felt de-motivated to the point o f wanting to exit the programme before its completion.

Purpose and objectives
The purpose o f this study was to in vestigate the perceptions of registered nurses with regard to continuing for mal education.
The objectives were to:

Research design and methodology
A quantitative descriptive survey de sign, utilising a questionnaire was used to gather information about how regis tered nurses perceived continuing for mal education and to identify the barri ers to continuing formal education.
A ccording to B abbie and M outon (2002:80), descriptive research provides a detailed picture o f participants' views or engagement in specific behaviours which can then be stated in numerical terms and the frequency with which a specific characteristic or variable oc curs in a sample.

Population and sample
The population comprised registered nurses employed at four state health institutions in the Western Cape Prov ince in South Africa: two tertiary hos pitals, a secondary level hospital and a primary health care clinic.The specific health institutions were chosen as a number of registered nurses employed at these institutions had accessed a post registration nursing programme and the researcher had easy geographi cal access to these institutions.
Convenience sampling was the method employed in this research, using the most conveniently available people as subjects in the study (Terre Blanche & Durrheim 2002:380).Registered nurses who were on duty on the days when the researcher visited the health insti tutions to deliver the questionnaires were included in the sample.A total of 70 registered nurses indicated their will ingness to complete the questionnaire but only 40 registered nurses com pleted and returned the questionnaires.Willing participants were not excluded on the basis o f th e ir not having accessed a continuing formal educa tion programme as it was appreciated that they too would be able to answer the questions pertaining to the purpose and objectives of the research.

The questionnaire as data collection instrument
A 61 item closed-ended questionnaire was developed which contained sec tions on demographic information; rea sons for engaging in continuing for mal education; motivators for continu ing formal education; benefits of, and perceived barriers to continuing formal education.Instructions were provided on how to complete the questionnaire using a 4 point Likert scale ranging from strongly agree to strongly disa gree.The summation feature o f a likert scale enables finer discriminations among respondents with different view points (Polit & Beck2008:420).
The questionnaire was pre-tested by three registered nurses who did not form part o f the research sample.The purpose o f pre-testing was to identify and correct am biguous questions, questions that people could not answer and grammatical and/or numbering er rors.Where there was mutual agree ment, the questionnaire was altered based on the principle that a question naire that could be interpreted differ ently by different people was unlikely to produce meaningful and reliable in formation.

Data collection and analysis
The questionnaires were self-administered and anonymous.The registered nurses were asked to participate in the study by completing the questionnaire.
Instructions in the form of a letter were attached to the questionnaire with in structions on how to complete every section of the questionnaire.The letter contained details o f the purpose of the research and the process for deliver ing the completed questionnaires.O f the 70 questionnaires administered, 40 w ere com pleted and returned (57.1%).The raw quantitative data were subjected to descriptive statistical analysis based on calculations using the Microsoft (MS) Excel (for Windows 2000) programme.

Ethical considerations
The

Demographic information
The m ajority o f respondents 80% (n=32), were in the age group 36 -55 years whereas 47.5% (n= 19) were mar ried and 52.5% (n=21) were single and within these two groups 62.5% (n=25) had children.The mean number o f years that the respondents had been qualified as registered nurses, was 21.15.This indicates that they were ex perienced nurses who should have been exposed to continuing formal edu cation to maintain relevance in their practice.Atkinson, Atkinson, Smith, Bern and Hilgard (1990:110), propose 40-65 years as being in the "middle years" o f adulthood and that these are the most productive years as men are usually at the peak of their careers and women have fewer responsibilities at home because children are growing up and they have therefore more time to devote to career activities.

Reasons for engaging in continuing formal education
Respondents had to respond to items to indicate which reasons had in the past or would in future, prompt them to engage in continuing formal education.
The agreed and strongly agreed re sponses were combined and the results are illustrated in Table 1.The entire group o f respondents 100% (n=40) agreed, th at they w anted to keep abreast with new developments in their areas o f speciality whereas 97.5% (n=39) agreed respectively that they would want to develop proficiency nec essary to meet their patients' expecta tions, and gain knowledge and skills not required during their basic nursing training.This shows that their reasons for engaging in continuing formal edu cation were not entirely self-centered but rather to promote the quality of nursing care to patients.The majority o f the respondents 97.5% (n=39), agreed that they wanted to de velop leadership capabilities whereas 92.5% (n=37) respectively agreed that they would engage in continuing for mal education to effectively mentor newly qualified nurses/students; im prove their confidence; plan their ca reer pathways; and improve their pros pects for remuneration.Modic and Schloesser (2006:96) (2005:22), who emphasises that educa tion allows the nurse to look at the wider issues around practice, and meeting patients' needs more efficiently.

Motivation for engaging in continuing formal education
The respondents were asked to re spond to statements pertaining to what would motivate them to undertake a programme o f continuing formal edu cation (Table 2).The motivators for engaging in continuing formal educa tion, given as a combination o f agree and strongly agree responses, were: prospects of promotion and remunera tion 80% (n=32); assistance with work ing out a career pathway 75% (n=30); funding assistance 72.5% (n=29); role models who demonstrate the value of career development 72.5% (29); recent success in a study programme 70% (n=28); peer encouragement 67.5% (n=27); encouragement from manage ment 62.5% (n=25); obtaining a SANC qualification with scarce skill allowance 62.5% (n=25); and a study skills course prior to commencement of a formal pro gramme 62.5% (n=25).It appears that apart from financial and promotional motivators, supportive structures in the work environment such as assist ance from management, peer encour agement and good role models also act as strong motivators.Nolan, Owens and Nolan (1995:553), found individual motivation as one o f the most signifi cant factors contributing to participa tion in continuing professional devel opment and added that it is easier to implement change when employees are highly motivated, the environmental infrastructure is supportive and the change initiative is widely accepted as relevant.

Benefits of continuing formal education
The questionnaire statements regard ing the benefits o f continuing formal education were applicable to the ma jority of the respondents 85.0% (n=34).
The respondents who had never accessed a programme o f study since registration 15.0% (n=6), were not able to answer this question.A closedended question was stated -whether or not respondents had benefited from a programme o f continuing formal edu cation.Respondents who concluded that continuing formal education had been beneficial 67.6% (n=23), were given the opportunity to elaborate in an open-ended question.The aspects mentioned most frequently included: financial and promotional prospects (n=8); enhanced know ledge base (n=7); and the development o f leader ship skills (n=5).Smith and Topping (2001:341 -349) ex amined the relationship between under taking a post-registration nursing course and the perceived benefits to the nursing practitioners.The per ceived benefits were improved knowl edge, improved care delivery, and pro fessional development.

Barriers to continuing formal education
Investigating the barriers to continu ing formal education could provide the means to devising innovative means to facilitate and foster a culture o f life long learning.The results showed that respondents perceive the following as barriers to engaging in continuing for mal nursing education programmes (  (2006:51), employees must get sufficient opportunities to realise their full poten tial and to experience job satisfaction and job involvement.Jooste (2003:150) strongly supports this view by refer ring to people as the greatest asset of any organisation and states that they must be cared for and valued as em ployees and not manipulated.

Conclusion
The findings of this study revealed that registered nurses recognise the ben efits of continuing formal education not only for themselves but also for the patients, as the main reasons provided for pursuing continuing formal educa tion were to keep abreast with devel opments in areas o f speciality and to develop the necessary proficiency to meet patients' needs.There was also strong evidence that the participants in this study, the majority of them be ing in senior positions (85%), want to develop leadership capabilities and be effective mentors for junior staff.

Limitations of the study
A limitation o f the study was the re sponse rate of 57% (n=40) which im pedes the generalisation of the research results.Generalisation o f the research results is further limited because the study was conducted in only four health care institutions.However, there is both a possibility and a need for the research to be replicated in other health care institutions across other provinces in South Africa.

Table 3
Nursing research in action.Develop ing basic skills.2M edition.London: MacMillan.BURNS, N & GROVE, SK 2001: The practice o f nursing research: conduct, critique and utilization.4th edition.Phila delphia: WB Saunders.