INTRODUCTION:

Continuing education are courses that are designed to help an individual develop his or her knowledge and skills in a specific area. Continuing education courses are offered to adults in the community by local school boards, colleges and universities. These courses can be on everything from web design to philosophy to art appreciation. Some schools may offer certificate programs, but usually the focus of continuing education is on non-credit courses that allow one to develop a specific area of interest.

A university degree or college diploma holder may take continuing education courses to upgrade their skills (Ontario Council of Agencies Serving Immigrants, 2015).

Health professionals enter the field armed with the knowledge they need to excel in their careers. However, health care is a changing field with constant new developments and so continuing education is needed to prepare health professionals for these changes (Upson, n.d.). According to Berings (2006), continuing education is increasingly necessary for nurses to keep abreast of rapid changes in patient care due to advancement in knowledge and technology. Continuing education for nurses provides an educated and informed workforce, who provides the best health services to the population (World health Organization, 2015). Jones (2005) in emphasizing the importance of continuing education for nurses maintained that, quality indicators such as risk of medication errors, patients falls, pressure sores and nosocomial infections are markedly reduced by two important factors that is, ongoing education and adequate number of skilled personnel.

Aiga and Kuroiwa (2006) argued that, nurses need to continually learn and apply new skills and knowledge, without such learning opportunities, nurses particularly those in the rural areas will experience a decline in skills, knowledge, professional dissatisfaction, low morale, disillusion, lack of commitment and reduced interest in their work. Most countries including China mandate their nurses to participate in continuing education due to the effect that lack of continuing education can have on health care delivery (Nursing and Midwifery Board of Australia, 2009). In these countries, each nurse must obtain a specific number of credits within a certain period of time in order to remain credentialed and to continue working.

The term continuing education has been coined from two words, that is continuous and education. These two terms have been described by several dictionaries as follows:

Merriam Webster’s dictionary defines the two terms as: Continuing means without stopping, happening or existing without break or interruption. Education is the action or process of teaching someone especially in school, college, or university.

Cambridge dictionary defines the two terms as: Continuing means to keep happening or doing something. Education is the process of teaching or learning, especially in a school or college.

Continuing education as a concept is often used as a substitute for associate terms such as continuing professional development, further education, lifelong learning, and adult education thus highlighting a need for its clarification.

Continuing professional development according to American Nurses Association (ANA ,2011), is a lifelong process of active participation by nurses in learning activities that assist in developing and maintain their continuing competence, enhancing their professional practice and supporting achievement of their career goals.

Lifelong learning refers to making sense of life experiences and using these meanings in thinking, solving problems and making choices and decisions; and acting in ways that are congruent with these choices and decisions as a means of obtaining feedback to confirm or disconfirm meanings (Mackeracher, 2004).

PURPOSE/ AIM:

A considerable number of concepts within nursing theory, practice and research have been constructed using concepts adopted from other discipline. The purpose of this concept analysis is to re-examine the concept “continuing education” for its meaning, relevance and appropriateness of application.

Definition and Uses of the Concept:

Oxford Advanced learner’s dictionary defines continuing education as education provided for adults after they have left the formal education system, consisting typically of short or part-time courses. Cambridge advanced learner’s dictionary defines continuing education as college classes for adults who have finished their school education, in a range of different subjects.

Merriam Webster’s dictionary defines continuing education as formal courses of study for adult part time students. Thesaurus defines continuing education as being synonymous with adult education and is defined as a programme of non-credit courses for adults regardless of previous education, offered by a university extension or institute. Macmillan dictionaries definition: lessons for adults often held in the evening that gives them the opportunity to study a variety of subjects.

Continuing education is a type of education and training used to provide knowledge and skills that keeps the engineer productive in their field. It may include advanced degree programmes in which one may enroll after finishing formal education and entering industry. It may also be intended strictly to complete a formal process of education (Groen and Kwalilak, 2014). Landers, Mcwhorter, Krum and Glovinsky (2005) define continuing education among physical therapist as a formal crucial component of professional development, which is a practical way of staying abreast with ongoing changes in health care environment. Continuing education offers the practitioners opportunities in emerging science, applying innovation in clinical settings and expanding care for patients. The authors opined that continuing education prevents professional obsolescence by staying current with new developments in theory and practice and to prevent skill and knowledge deterioration. Mcwhorter, Krum and Glovinsky (2005) argued that, in the light of rapidly expanding knowledge, continuing education should be constant in a professional’s life. Richards (2007) defines continuing education as a programme of study undertaken after registration as a general nurse, leading to the registration of an additional qualification or a higher degree in a health related field. Continuing education is a lifelong professional development process which takes place after the completion of the pre-registration nurse education programme. It consists of planned learning experiences which are designed to augment the knowledge, skills and attitudes of registered nurses for the enhancement of nursing practice, patient care, education, administration and research (An Bord Altranais, 1994).

Continuing education is defined by the Nursing Professional Development: Scope and Standards of Practice ( American Nurses Association [ANA] and National Nursing Staff Development Organization (NNSDO, 2010,p. 83) as systematic professional learning experiences designed to augmentthe knowledge, skills and attributes of nurses and therefore enrich the nurses’ contributions to quality health care and their pursuit of professional career goals.Continuing education refers to those learning activities intended to build upon the education and experiential bases of the professional registered nurse for the enhancement of practice, education, research or theory development, to the end of improving the health of the public and the registered nurse pursuit of their professional career goals (American Nurses Credentialing Center ANCC, 2011, p.106).

Continuing education includes planned learning experiences which lead to improvement of nurses’ attitude, skills and knowledge and consequently promote nurses’ function and care plan in the societys (Ellis and Hartley, 2012). Rogers (1996) defines continuing education as a purposeful planned learning, contrived to contribute to systematic growth and the effect of this is cumulative. Continuing education is a process of planned activities based on performance review and setting of explicit targets for good clinical practice with the aim of improving actual quality of care (Ni, Hua, Shao, Wallen, Xu and Li, 2014). Furze and Pearcey (1999) define continuing education as educational activities intended to expand the educational experience base for health professionals and to strengthen practice, education, administration, research and theoretical development with the view to improving the health of patients. Continuing education in nursing includes all educational activities beyond the basic nursing programmes (Warley and Itzpatrick, 1985).

Defining Attributes:

Defining attributes similar to signs and symptoms are critical characteristics that help to differentiate one concept from related concept and clarify its meaning (Walker and Avant, 2005). Four key defining attributes have been identified for the concept of continuing education.

· Adult Participants who are registered with a professional body and are practicing.

· Formal education which is offered by universities, institutions and certificates awarded.

· The course should provide knowledge and skills and build on the competence of the participant.

· Keeping the participant abreast with ongoing changes in the health care environment.

Four categories of cases are provided to further expand the concept of continuing education. The model case demonstrates all of the defining attributes of the concept while the borderline case contains most of the attributes but not all of them, the related case is related to the concept but does not contain the critical attributes and finally the contrary case is a clear example of what the concept is not. These cases help more to fully articulate the meaning of the concept.

Model case:

The pediatric unit of Akwasikrom Government Hospital in the Eastern Region of Ghana records higher neonatal deaths yearly and little has been done to solve the problem which has made the entire community very worried and sad, because they are losing their potential future leaders. Eunice who is a nursing officer and had worked for 6years at the Akwasikrom Government Hospital decided to upgrade her skills and knowledge in pediatric nursing at the University of Ghana, Legon. She was granted study leave to pursue the program. After two years, she graduated with a degree in pediatric nursing, went back to her hospital and was made in charge of the pediatric ward. Upon resuming duty, she made recommendations to the hospital management team. For the pediatric ward to live to expectation, a Neonatal Intensive Care Unit (NICU) and other equipment, medications and some policies needed to be provided. The NICU was established, with new incubators, oxygen cylinders, pediatric dextrose and many others. Eunice, her colleagues, the hospital and the entire community were happy with these new developments. Eunice then developed a protocol on the management of neonates, preterm and asphyxiated babies and educated all her colleagues on the protocol. Improvements were seen in the care of the neonates; they got well and were discharged home after few days of admission without complications.

Analysis of the model case:

· Eunice is a registered nurse who has worked for six years.

· She studied pediatric nursing at the University of Ghana and was awarded a degree in pediatric nursing.

· The course built on the competence of the nurse, this is because she identified the problems within the pediatric ward and made recommendations as to how they could be resolved.

· Through the knowledge she acquired, Eunice ensured that, the NICU and the available equipment met the standards for caring for neonates.

Boarder line case:

The quality assurance team of the Mangoase hospital in the Ashanti region conducted performance assessment for all nurses within the facility. They found that, Sylvia who was a theatre nurse and had worked for seven years on the surgical ward performed below standard. A need assessment was done to find out what could be done to assist her improve on the quality of care she rendered to her surgical patients. An agreement was made between Sylvia and the hospital management to enroll her in the post -operative nursing programme at the school of nursing, Legon. She completed the programme after a year with a certificate. After school she returned to the surgical ward. Sylvia remained to her old ways of practicing, no new change was observed, she still used non sterile gloves in dressing surgical wounds, no wearing of face mask and dressing wounds from the outside of the wound to the inner portions of the wound as a result, her patients’ wounds got infected and they had to spend longer days on admission.

Analysis of the boarder case

· Nurse Sylvia was a registered nurse who had worked for seven years.

· She needed improvements in the quality of care provided to her surgical patients.

· She graduated from the post –operative nursing program at the school of nursing, Legon with a certificate.

· Sylvia stacked to her old ways of practicing; she did not demonstrate that she knew the current trends in surgical wound management.

Related Case:

Kofi Manu, 20years of age, graduated with BSc. Psychology from Kwame Nkrumah University of Science and Technology, Kumasi in 2011. After staying in the house for two good years without being employed by any organization, he furthered his education by pursuing MPhil in Clinical Psychology at the same university hoping that after school he will secure a better job.

Analysis of the Related Case:

Kofi Manu has engaged in continuing education, because after his BSc. Psychology he pursued MPhil in Psychology which broadened his knowledge and skills in the field of psychology.

Contrary Case:

Abigail is a staff midwife and has worked for three years within her hospital, because she wants to upgrade and update her knowledge in the quality of care she provides for her patients, she ensures that, she attends all the in-service trainings, workshops, seminars and conferences organized in and outside her hospital. As a result of her rich knowledge in the profession, she is regarded as one of the competent nurses within her facility. She provides quality care to her clients and is abreast with the current trends in midwifery. She in turns organizes in- service training for her colleagues on the ward.

Analysis of Contrary Case:

This is a contrary case because continuing education is formal education courses organized by training institutions and are not limited to in-service trainings, seminars, workshops and conferences.

Antecedent:

Walker and Avant (2005) define antecedents as the events or attributes that must arise prior to the occurrence of the concept. The following antecedents have been identified.

Self-Development:

Most nurses pursue continuing education because of an inner desire to do so. Landers et al., (2005) in their study found that, physical therapists who engaged in continuing education were intrinsically motivated to pursue continuing education in that, they wanted an expansion in their clinical competence and for certification purposes and these propelled them to learn. This is similar to Gorczyca’s (2013) findings. She argued that, participants desire to participate in continuing education came from a desired to be challenged academically and professionally. To them they would be motivated to take up a challenge that fulfills their personal need for learning and as well provide them with new professional developments. Kovner, Brewer, Katigbak and Djukic (2012) also found that, diploma prepared nurses’ who lived in rural areas were more likely to obtain a bachelor’s degree or a higher one than those from urban areas three to five years after completion from diploma programmes because these nurses wanted to achieve personal and job satisfaction.

Availability of funds:

The high cost of tuition fees for continuing education programmes has deterred many nurses from pursuing continuing education. Kovner et al. (2012) opined that, cost was identified as a major resource to pursue additional education, one could pursue continuing education if he or she had more than one job, working more voluntarily overtime and earning a higher income.According to Gorcyzca (2013), participants in her study stressed on the financial struggles, they anticipated if they had to pursue graduate education. Only few health care providers (particularly nurses) are given study leave with pay, leaving those eager to develop their professional competences to wait for quite a longer time instead of the three year period of service for one to qualify for study leave with pay (Aiga and Kuroiwa, 2006). Groen and Kwalilak( 2014) in their study recommended that, there should be a collaboration between the stakeholders of continuing education such as the government, professional bodies, continuing education researchers and practitioners selected from universities, private industries to develop support activities such as financial aid to help nurses who want to pursue continuing education. Kovner et al. (2012) also maintained that, institutional funding incentives should be offered for advancing the education of nurses. Nurses who are interested in pursuing continuing education should be identified and supported to enroll and complete continuing education programmes with tuition reimbursement and scholarship funds.

Awareness of accessible educational programs:

Glass and Todd–Atkinson (1999) surveyed registered nurses and licensed practicing nurses across randomly selected facilities in north Carolina in the United States of America (USA) to ascertain their self-perceived learning needs, among their findings were the need to be aware of readily available nurse education programmes and educators ensuring that continuing education programmes are relevant to the current environment in which health care is delivered. For nurses to engage in continuing education, it should be exciting by making the learning experiences more diverse and more appealing. Educators can help sustain enthusiasm in nurses who want to learn and those less stimulated to learn by employing morestudents–centered approaches when planning continuing education programmes (Griscti and Jacono, 2006). Lack of knowledge about learning opportunities, prohibitive entry requirements to post- registration programmes and late advertising of educational programmes have become a hindrance to pursuing continuing education (Leading Learning and Skills [LLS], 2005).

Adequate staffing:

In the presence of inadequate staffing, nurses may not be given the opportunity to pursue continuing education. A study by white in the United States of America (USA) concluded that, the health service manager is faced with the challenge of encouraging his or her own continuing education as well as that of others in the face of the cycle of a reduced pool of potential recruits into the profession, sicker patients and a smaller work force. Nurses are increasingly working overtime. Mandatory overtime imposed by the employer or voluntary overtime work in addition to regular contracted hours have been used as a measure to reduce the impact of critical shortage of nurses making it difficult for individual nurses who are interested in continuing education to pursue it (International Council of Nurses, 2011). As a result of inadequate staffing, most nurses pursuing continuing education may opt for night duties but the International Council of Nurses (2000) maintains that, this will have a negative impact on an individual’s health and ability to function. Burley as cited in Hoban (2005) opined that nurses cannot be sent away for long periods of time. This is because there is no point having highly trained nurses if there is no one left to care for patients.

Consequences:

Consequences are those events or incidents that can occur as a result of the occurrence of the concept and that can often stimulate new ideas or avenues for research (Walker and Avant, 2005).

Improvement in quality care:

When nurses pursue continuing education there is an improvement in the quality of care rendered to their patients. Osterman, Asselin and Cullen (2009) in their qualitative study of how Bachelor of Science influences the professional nurse; most of their participants concluded that, pursuing continuing education has extended their scope of nursing care, they opined that patient be viewed as a whole. To them in caring for the patient, it is important to consider the patient as a sum of its parts. One needs to focus on the physiological, spiritual, psychological, social aspect of the client in order to give an efficient care. Similarly, Aiken, Clarke, Cheung, Sloane and Silber (2003) also found out that, hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality rate. Their findings revealed that, if the proportion of bachelor science nurses in all hospitals was 60% rather than 20%, fewer deaths per 1000 patients would be expected. Upson (n.d.) as cited earlier also emphasized that when there is adequate number of skilled staff who has undergone continuing education; quality indicators such as medication errors, patient falls, pressure sores and nosocomial infections are markedly reduced.

Empowerment of nurses:

Nurses who undergo continuing education become empowered and enlightened about the nursing profession. Osterman et al. (2009) submitted that most of their participants agreed that, they have identified a basic broadening of their own knowledge about the scope of the profession. Through their bachelor of nursing programme, they have come to know about the nursing profession, nursing theories and the use of internet in finding nursing theories. Other participants also argued that, their way of thinking has been shifted from practice that was automatic, almost rote to creative intuitive problem solving approach and their training has offered them the opportunity to differentiate between a nurse leader and a nurse manager.

Manojlovich (2007) studied nurses’ participation in decision making at the magnet hospital. The basic qualification of these nurses is Bachelor of Science in nursing. Nurses’ involvement in hospital affairs is one of the hallmarks of magnet hospital environment. He found that, nurses were able to influence decisions and were in control of their own practice, while recognizing the power of physicians and nurse leaders. Nurses who do not pursue continuing education are powerless, ineffective, less satisfied with their jobs and more susceptible to burnout.

Acquiring credentials to expand one’s role:

Nurses who pursue continuing education are promoted to various ranks within the nursing profession. Osterman et al. (2009) opined that, nurses who have undergone continuing education advocate for administration, management and physician support. They promote a shared decision model and ensure that student nurses participate in the decision making. They recommend that, baccalaureate –prepared nurses serve as preceptors and resource nurses, and should be given the opportunity to use and share their knowledge.

Buhr (2010) also undertook a study which sought to determine whether a higher probability of promotion was as a result of increasing one’s education. Data from the confidential master files from the 2001 Canadian census on individuals were used for the study. The study provided empirical evidence to show that registered nurses with a bachelor’s degree stood a better chance of being promoted to supervisory positions. Samples comprising both males and females indicated that a bachelor of nursing certification yields a 4% higher probability of promotion to a supervisory position compared with other educational credentials.

Growth and development of the nursing profession:

Nurses who pursue continuing education contribute to the growth and development of the profession. According to the Institute of Medicine (IOM, 2015) report on the future of nursing: focus on education, transforming the healthcare system to provide safe, quality, patient centered, accessible and affordable care will require a comprehensive rethinking of the roles of many health care professionals, chief among them is nurses. To achieve this objective, education must be fundamentally improved both before and after nurses receive their licenses. Achieving this objective is essential because we need more nurses with advanced degrees to provide primary care and teach the next generation and occupy leadership positions in nursing. Gorczyca (2013) expatiated on the objective of (IOM) that, nurses at all levels of education have experience which can shape nursing practice but it is only those who pursue graduate studies who gain research and advanced critical thinking skills required to take on higher level positions in the nursing domains of advanced clinical practice, research, leadership, administration and education.

Houston (2013) concedes that, there are emerging technologies such as genetics and genomics, biometric, electronic health record and less invasive and more accurate tools for diagnosis and treatment that will change the practice of nursing. Nurses will have to acquire skills to develop, acquire and integrate these emerging technologies and without continuing education, this will pose a great challenge to nursing leaders. Witt (2011) contended that, participation in continuing professional education offers the practitioner the opportunity for networking, career growth and opens doors to new opportunities. The participant in continuing education gets the opportunity in attending national conferences. For example, the National Association of Neonatal Nurses national meetings offers a number of educational opportunities such as poster presentations of best practices and new researches, pre conference seminars on topics of interest which enlightens the participant and throws a challenge to her to also contribute her quota to the nursing profession.

Empirical Referents:

Empirical referents are measurable ways to demonstrate the occurrence of the concept (Avant and Walker, 2005). Some identified measuring scales of the concept education identified are: Self-Directed Learning Readiness Scale (SDLRS) measures adult readiness to engage in self-directed learning (Hoban, Lawson, Mazmanaian, Best and Seibel, 2005), Adult Attitudes Torwards Continuing Education Scales (AACES) to determine adult attitudes towards continuing education by Darkenwald and Hayes (1988), Deterrents to participation Scale General (DPS-G) to identify perceived deterrents to participation in adult education by the general population by Darkenwald and Valentine (1985); and National Survey of Student Engagement Measures (NSSE) student participation in educational in educational experiences (Chickering and Gamson, 1987; Kuh, 2001, 2003).

CONCLUSION:

A first step towards developing a theory of continuing education is a systematic analysis of the concept. This concept analysis has identified the defining attributes, antecedents and consequences of continuing education. The next step in the development of the theory of continuing education is the construction and testing of theoretical relationships between perceptions, motivation and barriers to continuing education. Systematic studies of continuing education, whether quantitative or qualitative can be carried out to find out the impact of continuing education on nursing practice and this will ultimately enhance nursing science and promote professionalism in nursing.

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Received on 18.05.2017 Modified on 21.10.2017

Asian J. Nursing Education and Research. 2018; 8(2): 288-294.

DOI: 10.5958/2349-2996.2018.00056.3