Article 1

Research Article

Perceptions of registered nurses in fourstate health insititutions on continuing

formal educationL Richards, MA Health StudiesLecturer, University of the Western Cape

EPotgieter,D Litt et PhilAssociate Professor, Department of Health Studies, Unisa.

Key wordscontinuing formal education; registerednurse; perceptions; motivation; physi-cal barriers; structural barriers.

Correspondence addressProfEPotgieterDepartment of Health StudiesUNISA

Tel: (012)429-6545Fax:(012)429-6688E-mail: [email protected]

Abstract: Curationis 33 (2): 41-50This study investigated registered nurses in four selected state health institutions'perceptions with regard to continuing formal education. The relevance of continuingformal education is being emphasised globally by the increasing quest for qualityassurance and quality management systems within an ethos of continuous improve-ment. According to Tlholoe (2006:5), it is important to be committed to continuallearning, as people's knowledge become less relevant because skills gained early ina 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 inhealth care delivery. The study described:

• registered nurses' views on continuing formal education

• registered nurses' perceived barriers to continuing formal educationA quantitative descriptive survey design was chosen using a questionnaire for datacollection. The sample consisted of 40 registered nurses working at four state healthinstitutions in the Western Cape Province, South Africa. Convenience sampling wasselected to include registered nurses who were on duty on the days during which theresearcher visited the health institutions to distribute the questionnaires. The ques-tionnaire contained mainly closed-ended and a few open-ended questions. Contentvalidity of the instrument was ensured by doing a thorough literature review beforeconstruction of items and a pretest. Reliability was established by the pretest andproviding 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 relevantauthorities. Descriptive statistics, based on calculations using the Microsoft (MS)Excel (for Windows 2000) programme, were used to summarise and describe theresearch results. The research results indicated that most registered nurses perceivecontinuing formal education as beneficial to their personal and professional growthand that it could lead towards improving the quality of patient/client care, but barriersexist which prevent or deter them from undertaking continuing formal educationprogrammes. The main structural barriers included lack of frmding and lack of coher-ent staff development planning and physical barriers including job and family re-sponsibilities.

41Curationis June 2010

Table 1: Reasons for engaging in continual formal education (N=40)

Reason for engaging in con-tinuing formal education

To keep abreast with devel-opments in the area of spe-ciality

To develop proficiency nec-essary to meet patients' ex-pectations

To gain knowledge and skillsnot obtained during basictraining

To develop leadership capa-bilities

To be an effective mentor fornewly qualified nurses/nurs-ing students

To improve confidence

To plan a career pathway

To improve prospects of re-muneration and promotion

To network with other nurs-ing colleagues

To obtain an additionalqualification

To provide a break from thepressures of work

n

12

9

14

13

9

16

17

20

18

5

7

Agree

%

30.0

22.5

35.0

32.5

22.5

40.0

42.5

50.0

45.0

12.5

17.5

n

28

30

25

26

28

21

20

17

9

6

3

Stronglyagree

%

70.0

75.0

62.5

65.0

70.0

52.5

50.0

42.5

22.5

15.0

7.5

n

0

1

1

1

3

2

1

1

8

10

17

Disagree

%

2.5

2.5

2.5

7.5

5.0

2.5

2.5

20.0

25.0

42.5

n

0

0

0

0

0

0

2

2

3

17

13

Stronglydisagree

%

5.0

5.0

7.5

42.5

32.5

Un-answered

n %

0

0

0

0

0

1

0

0

2

2

0

2.5

5.0

5.0

n

40

40

40

40

40

40

40

40

40

40

40

Total%

100

100

100

100

100

100

100

100

100

100

100

IntroductionThe World Health Report emphasisesthe need for strategic plaiming withregard to continuing education forhealth care providers. Human re-sources are the most important of thehealth system's resource inputs. Theperformance of health care systems ul-timately depends on the knowledge,skills and motivation ofthe people re-sponsible for delivering services. Edu-cation and training are key investmenttools as old skills become obsolete withthe advent of new technologies (WorldHealth Organisation [WHO] 2000:76).The relationship between societal andtechnical 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 andchallenges in the health care environ-ment (Peck, McCall & Rotem 2000:432).

Professionalism relies increasingly onan ability to respond quickly to chang-ing market conditions, to client require-ments, and to the influence of govem-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 ofnegligence than in the past. Health careprofessionals work in a very structuredenvironment where reg;ulation and ac-countability for practice are required.Nursing deals with complex humanproblems, and cannot limit itself to acircumscribed body of information. Inorder to respond to the array of prob-lems that nurses confront, the profes-sion as a whole and its members indi-vidually must be encouraged to profitfrom every source of knowledge(Eustace 2001:134; Page 2004:29). Oneof the primary roles of professionalbodies is to safeguard standards ofcompetence. The South African Nurs-ing Council determines professional

42Curationis June 2010

Table 2: Motivation for engaging in continuing formal education (N=40)

Motivation for engaging incontinning formal edncation

Prospects of promotion andremuneration

Assistance with working outa career pathway

Funding assistance

Role models who demon-strate the value of career de-velopment

Recent success in a studyprogramme

Peer encouragement

Encouragement from man-agement

Obtaining a S ANC qualifica-tion with scarce skill allow-ance

A study skills course priorto commencement of a for-mal programme

n

21

22

22

20

22

22

21

16

19

Agree%

52.5

55.0

55.0

50.0

55.0

55.0

52.5

40.0

47.5

n

11

8

7

9

6

5

4

9

6

Stronglyagree

%

27.5

. 20.0

17.5

22.5

15.0

12.5

10.0

22.5

15.0

Disagreen %

4

5

7

9

7

10

11

8

9

10.0

12.5

17.5

22.5

17.5

25.0

, 27.5

20.0

22.5

n

3

4

3

1

3

2

3

6

5

Stronglydisagree

%

7.5

10.0

7.5

2.5

7.5

5.0

7.5

15.0

12.5

Un-answeredn %

1

1

1

1

2

1

1

1

1

2.5

2.5

2.5

2.5

5.0

2.5

2.5

2.5

2.5

n

40

40

40

40

40

40

40

40

40

Total%

100

100

100

100

100

100

100

100

100

standards. In so doing, health care us-ers are afforded the services of a com-petent professional nurse. The chal-lenge for nurse education includes fos-tering the competence of the nurse toensure that she/he can implement evi-dence-and-research-based practice thatguides the nurse in sound decisionmaking (Van Wyk 2006:45).According to Myers (2001:1), the aimsof continuing formal education are tomaintain knowledge and skills, to im-prove existing competencies and todevelop new competencies with theultimate aim of improving patient care.This is affirmed by Smith & Topping(2001:342), wiio view improved knowl-edge, improved care delivery and pro-fessional development as some of themajor benefits of post registration nurs-ing courses.

Background and iiteraturereviewThe nursing profession is accountable

to society for providing high-qualitycare for patients and families. Nursestherefore have to maintain competen-cies and keep up to date with the mostrecent research and developments inpatient care. According to Smith andTopping (2001:342), professional con-tinuing education empowers nurses tostay effective in their jobs and improvequality in health service delivery.A review of relevant literature revealedmany studies which describe the ben-efits of continuing formal education butseveral authors report that there arealso barriers to continuing formal edu-cation.

Benefits of continuing formaleducationEffective continuing education hasbeen linked with raised staff morale, in-creased motivation and staff retention.Reasons given by nurses for engagingin continuing education include en-hancement of professional knowledge;advancing professionally; providing

relief from routine; improvement of so-cial relations; and acquirement of cre-dentials. In most circumstances con-tinuing formal education in nursing isaccompanied by the development ofleadership skills evidenced by the abil-ity to inspire followers, master uncer-tainty, foster confidence and accommo-date criticism (Ehrat 2001:36-42; Eustace2001:134).

Continuing formal education pro-grammes have a range of functionscomprising a maintenance role whichfosters the notions of life-long learn-ing; a survival role requiring practition-ers to demonstrate their ongoing com-petence; and a mobility role \\Wch aimsto increase a person's employability. Asnursing becomes more complex nursesare required to be more knowledgeable,and the more health professionals learnthe more they will challenge the tradi-tional practices, embrace change andfoster innovation (Lawton &Wimpenny 2003:41 ; Eustace 2001:134;

43Curationis June 2010

Table 3 : Barriers to engaging in continuing formal education (N=40)

Barrier to engaging in con-tinuing formal education

Lack of funding

Job responsibilities

Conditions attached to thegranting of study leave

Lack of employer co-opera-tion (eg funding)

Family and child care re-sponsibilities

Lack of coherent staff de-velopment plans by the in-stitution

Lack of a supportive workenvironment

Lack of opportunities forpromotion

n

19

13

16

19

13

18

12

12

Agree%

47.5

32.5

40.0

47.5

32.5

45.0

30.0

30.0

Stronglyagreen %

9

14

9

5

9

3

8

8

22.5

35.0

22.5

12.5

22.5

7.5

20.0

20.0

n

8

11

13

14

13

18

19

19

Disagree%

20.0

27.5

32.5

35.0

32.5

45.0

47.5

47.5

n

4

2

1

1

5

1

1

1

Stronglydisagree

%

10.0

5.0

2.5

2.5

12.5

2.5

2.5

2.5

Un-answeredn %

0

0

1 2.5

1 2.5

0

0

0

0

n

40

40

40

40

40

40

40

40

Total%

100

100

100

100

100

100

100

100

Hoban 2005:22).Continuing formal education is the re-sponsibility of the individual as well asthe employing authority. The individualnurse has the right to expect the provi-sion of fraining opportunities, and theemployer should expect the nurse tomaintain and develop the skills forwhich she/he is employed (Jooste2005:53). Organisations which do notinvest in the career development oftheir employees may discover that theirorganisation is characterised byunmotivated employees who are disin-terested in career development and lackcommitment to the organisation (WHO2000:76).

Whether in the private or the increas-ingly privatised public/state sector, thecompetitive market edge must be fo-cused on client care/service quality andtechnological innovation. This de-mands a high investment in develop-ing people's skills if they are to be ef-fective. Through continuing formaleducation, the knowledge base of staffis improved with the consequence ofraising standards and producing a morecost-effective service. Lower levels ofabsenteeism and greater staff retentionrates have been reported. The health

care user and the health care institu-tion both benefit when health careworkers are empowered through in-creased competence and the accompa-nying confidence to take confrol of ajob and apply autonomous decision-making (Smith & Topping 2001:341 -349;G3ry2002:33).

Within today's rapidly changing glo-bal world professional competenceneeds to be maintained. Professionalcompetence is defined by Kennie (2000)in Enemark and Plimmer (2000:7), interms of four components: knowledgecompetence — the possession of tech-nical and/or business knowledge andthe ability to apply this in practice; cog-nitive competence - the ability to prob-lem solve using high level thinkingskills; business competence - the abil-ity to manage client expectations in apro-active manner; and ethical and/orpersonal behavioural competence - thepossession of appropriate personal andprofessional values and behaviours tobe able to make sound judgments whenconfronted with ethical dilemmas in aprofessional context.An affluent consumer society has de-veloped as a result of a better informed

and more sophisticated public. A con-sequence of this frend is that the pub-lic expect a higher duty of care and levelof service from their professional advi-sors than in the past. The skills ac-quired during an initial fraining periodmay not equip new staff for this role.Continuing formal education has impor-tant implications for both professionalnurses and for the general public. Thepublic has a right to be safeguardedagainst malpractice, and they have anexpectation that nurses will possessup-to-date knowledge and skills appro-priate to the specialist field in whichthey practice (Ironside 2008:92).

Barriers to continuing formaleducationWhile the literature points to the ben-efits of continuing formal education,there is an abundance of literaturewhich points to barriers to continuingformal nursing education. According toHoban (2005:24), neglect of profes-sional and personal development willresult in nursing lacking the credibilityit has always been seeking. Barriers toundertaking continuing formal educa-tion have been identified in severalstudies and classified into three cat-

44Curationis June 2010

egories.Physical barriers (situational) refer tolack of time because of job responsi-bilities; family and child care responsi-bilities; difficulties in paying coursefees; fear of losing benefits; and diffi-culty with numeracy and academic read-ing and writing skills (Penz, D'Arcy,Stewart, Kosteniuk, Morgan & Smith2007:59; Aoki & Davies 2002:902).Attitudinal barriers (dispositional)comprise negativity due to unpleasantpast experiences in academia; lack ofemotional and physical energy andconcem about not being able to keepup academically. The result is the nursehaving low aspirations and doubtsabout the value of continuing formaleducation; low self-esteem; lack of con-fidence both generally and in relationto leaming and lack of trust in the for-mal instittition (Xaba «& Phillips 2001:2;Horton-Deutsch & Mohr 2001:121-126).

Structural barriers (institutional)have been identified as lack of trans-port; unavailability of nearby educa-tion institutions; staff shortages; lackof knowledge about leaming opportu-nities, prohibitive entry requirements;lack of appropriate programmes; lateadvertising of professional educationalevents; lack of coherent staff develop-ment plans; difficulty in obtainingstudy leave; a non-inclusive style ofnursing management; and lack of sup-port from managers (Leading leamingand skills [LSC] 2005:2-4; Penz et al2007:59,60,62).

Problem statementIn South Africa, nurses carry the bur-den of a public health system battlingto overcome staff shortages, a grow-ing HIV/AIDS pandemic and under-resourced public health facilities whichresult in stressful working conditions.It is difficult to see beyond these harshconditions to how attaining a highernursing qualification will ease the bur-den of care and attract increased mon-etary reward. The researcher who, atthe time ofthe study, was a facilitatorfor a post-registration nursing pro-gramme, periodically conducted inter-views with nurses who were battlingto attend classes, complete assign-ments and who felt de-motivated to thepoint of wanting to exit the programmebefore its completion. The commentsreceived from these nurses includedlack of support from managers and col-

leagues; being overlooked for seniorposts in spite of having relevant postregistration qualifications; too muchwork stress; inability to manage study,work and family obligations; and guiltfeelings about studying in the face ofstaff shortages in the work setting.It was against this background that thisstudy sought to answer the followingquestion:WTiat are registered nurses' percep-tions of continuing formal educationand what are the barriers to continuingformal education?

Purpose and objectivesThe purpose of this study was to in-vestigate the perceptions of registerednurses with regard to continuing for-mal education.The objectives were to:

• Explore and describe registerednurses' perceptions of continu-ing formal education.

• Identify barriers to continuingformal education.

Definition of termsA Registered nurse has completed afour year comprehensive course lead-ing to registration vvith the South Afri-can Nursing Council as a nurse (gen-eral, psychiatric and community) andmidwife in terms of Regulation R425 of22 Feb 1985 as amended (Mellish &Brink 1996:50).Continuing formal education pro-grammes are defined as those whichlead to the registration of an additionalqualification with the South AfricanNursing Council (Searle, Human &Mogotlane 2009:70). In this study pro-fessional continuing education refersto formal educafion xmdertaken afterregistration of a first qualification in-cluding national diplomas, post basicnursing diplomas and degrees (Kotze2008:216).Perceptions refer to the act of havingknowledge and understanding of some-thing; an intuitive recognition of a truth(Collins English Dictionary 1992). Per-ceive means to apprehend with themind, observe and understand (Con-cise Oxford Dictionary 1982:819). In thisstudy, perceptions refer to registerednurses' knowledge and understandingof continuing formal education.Barriers refer to those aspects whichprevent access or progress (Collins

English Dictionary 1992). In this study,barriers refer to those physical,attitudinal and structural aspects whichprevent the registered nurse from en-gaging in, or completing a continuingformal education programme (Leadingleaming and skills [LSC] 2005:2-4).Motivate means to stimulate interest,it derives from motive which means atendency to initiate movement, some-thing which induces a person to act(Concise Oxford Dictionary 1982:711).Reason refers to a cause or justifica-tion (Concise Oxford Dictionary1982:930).

Research design andmethodologyA quantitative descriptive survey de-sign, utilising a questionnaire was usedto gather information about how regis-tered nurses perceived continuing for-mal education and to identify the barri-ers to continuing formal education.According to Babbie and Mouton(2002:80), descriptive research providesa detailed picture of participants' viewsor engagement in specific behaviourswhich can then be stated in numericalterms and the frequency with which aspecific characteristic or variable oc-curs in a sample.

Population and sampleThe population comprised registerednurses employed at four state healthinstitutions in the Westem Cape Prov-ince in South Africa: two tertiary hos-pitals, a secondary level hospital and aprimary health care clinic. The specifichealth institutions were chosen as anumber of registered nurses employedat these institutions had accessed apost registration nursing programmeand the researcher had easy geographi-cal access to these institutions.

Convenience sampling was the methodemployed in this research, using themost conveniently available people assubjects in the study (Terre Blanche &Durrheim 2002:380). Registered nurseswho were on duty on the days whenthe researcher visited the health insti-tutions to deliver the questionnaireswere included in the sample. A total of70 registered nurses indicated their will-ingness to complete the questionnairebut only 40 registered nurses com-pleted and retumed the questionnaires.Willing participants were not excludedon the basis of their not having

45Curatíonis June 2010

accessed a continuing formal educa-tion programme as it was appreciatedthat they too would be able to answerthe questions pertaining to the purposeand objectives of the research.

The questionnaire as datacollection instrumentA 61 item closed-ended questionnairewas 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, andperceived barriers to continuing formaleducation. Instructions were providedon how to complete the questionnaireusing a 4 point Likert scale rangingfrom strongly agree to sfrongly disa-gree. The summation feature of a likertscale enables finer discriminationsamong respondents with different view-points (Polit & Beck2008:420).The questionnaire was pre-tested bythree registered nurses who did notform part of the research sample. Thepurpose of pre-testing was to identifyand correct ambiguous questions,questions that people could not answerand grammatical and/or numbering er-rors. Where there was mutual agree-ment, the questionnaire was alteredbased on the principle that a question-naire that could be interpreted differ-ently by different people was unlikelyto produce meaningñil and reliable in-formation.

Reliability and validityReliabilityReliability refers to the consistency andstability with which an instrumentmeasures a target attribute. If the sameinstrument is administered to differentindividuals at different times, the re-sponses to the items should remain thesame (Bums & Grove 2001:396,809;Neuman 1997:138). Pre-testing of thequestioimaire contributed towards re-liability of the data collection instru-ment, measured in terms of askingabout things the respondents werelikely to be able to answer, and clarityof the questions (Babbie 1998:132).

VaiidityValidity refers to the degree to whichan itistrument measures what it is in-tended to measure (Polit & Beck2008:768). Content validity refers to thedegree to which an instrument has an

adequate sample of items of the con-struct being measured. (Babbie &Mouton 2002:123; Polit & Beck2008:458). To ensure content validity,a thorough study of relevant literaturewas done before constructing the ques-tionnaire. Thereafter the questionnairewas presented to an experienced nurseeducator at a higher education institu-tion and to a graduate registered nursefor comments on the content validityof the instrument.

Data collection and analysisThe questiormaires were self-adminis-tered and anonymous. The registerednurses were asked to participate in thestudy by completing the questionnaire.Instructions in the form of a letter wereattached to the questionnaire with in-structions on how to complete everysection of the questionnaire. The lettercontained details of the purpose of theresearch and the process for deliver-ing the completed questiormaires.Of the 70 questionnaires administered,40 were completed and returned(57.1%). The raw quantitative data weresubjected to descriptive statisticalanalysis based on calculations usingthe Microsoft (MS) Excel (for Windows2000) programme.

Ethicai considerationsThe ethical considerations of informedconsent, confidentiality and anonym-ity were upheld. Survey researcherscan intrude into a respondent's privacyby asking about intimate actions andpersonal beliefs, but the respondentdecides when and to whom to revealpersonal information. Respondents arelikely to provide such information whenthey believe serious answers areneeded for legitimate research pur-poses, and when they believe answerswill remain confidential. Researchershave a duty to treat all respondentswith dignity and to reduce anxiety ordiscomfort. Researchers are also re-sponsible for protecting the confiden-tiality of data. Informed consent in-volves respondents agreeing to answerquestions, refusing to participate in theresearch or to withdraw from the studyat any time without being penalised(Neuman 1997:130,264,450). Permissionto conduct the research was soughtfrom the management of the participat-

ing health care institutions and the re-search and ethics committee of the uni-versity endorsing the research. Theresearcher's name and the reasons forundertaking the research were madeknown to the respondents. They wereassured that responses would only beused for research purposes. The re-searcher used the mechanism of a writ-ten letter attached to each question-naire as the means of upholding theprinciple of informed consent. The re-searcher acknowledged the rights ofthe registered nurses not to participatein the study, and no respondent wascoerced into completing the question-naire.

Anonymity was ensured by not requir-ing from respondents to write theirnames on the questionnaires and theresearcher was therefore not able to linkthe respondents with the informationprovided. Confidentiality was adheredto by not reporting the research resultsin a manner which could identify therespondents or the institutions in-volved (Babbie & Mouton 2002:526;Polit & Beck 2008:180).

Results and DiscussionDemographic informationThe majority of respondents 80%(n=32), were in the age group 36 - 55years whereas 47.5% (n= 19) were mar-ried and 52.5% (n=21) were single andwithin these two groups 62.5% (n=25)had children. The mean number ofyears that the respondents had beenqualified as registered nurses, was21.15. This indicates that they were ex-perienced nurses who should havebeen exposed to continuing formal edu-cation to maintain relevance in theirpractice. Atkinson, Atkinson, Smith,Bem and Hilgard (1990:110), propose40-65 years as being in the "middleyears" of adulthood and that these arethe most productive years as men areusually at the peak of their careers andwomen have fewer responsibilities athome because children are growing upand they have therefore more time todevote to career activities.The largest group of respondents oc-cupied the post of Chief ProfessionalNurse 72.5% (n=29), followed by Sen-ior Professional Nurse 12.5% (n=5), andProfessional Nurse 15% (n=6). Thismeans, the majority of respondentsoccupy senior-level posts and there-fore have the responsibilities of lead-

46Curationis June 2010

ership and management and coordinat-ing the activities ofthe nursing team.A large number ofthe respondents hadpreviously participated in continuingformal education as 85.0% (n=34) havea post registration qualificationwhereas only 15% (n=6) had not ob-tained a post regisfration qualification.However, half of the respondents 50%(n=20), did not obtain a post basicqualification in the last 5 years and only15% (n-6), were currently (dtiring datacollection for this study) undertakinga programme of study. According toEnemark (2005:20), it is presently esti-mated that the knowledge gained in avocational degree course has an aver-age useful life span of about four years.If professionals have expectations ofincreased managerial responsibility theneed to acquire new skills and knowl-edge is even more acute.

Reasons for engaging incontinuing formal educationRespondents had to respond to itemsto indicate which reasons had in thepast or would in friture, prompt them toengage in confinuing formal education.The agreed and strongly agreed re-sponses were combined and the resultsare illustrated in Table 1. The entiregroup of respondents 100% (n=40)agreed that they wanted to keepabreast with new developments in theirareas of speciality whereas 97.5%(n=39) agreed respectively that theywould want to develop proficiency nec-essary to meet their patients' expecta-tions, and gain knowledge and skillsnot required during their basic nursingtraining. This shows that their reasonsfor engaging in continuing formal edu-cation were not entirely self-centeredbut rather to promote the quality ofnursing care to patients.The majority ofthe respondents 97.5%(n=39), agreed that they wanted to de-velop leadership capabilities whereas92.5% (n=37) respectively agreed thatthey would engage in continuing for-mal education to effectively mentornewly qualified nurses/students; im-prove their confidence; plan their ca-reer pathways; and improve their pros-pects for remuneration. Modic andSchloesser (2006:96) contend that asadults mature, they have the potentialto create a reservoir of experience thatwill cause them to become a rich sourceof leaming. The respondents agreed toa lesser extent that they would like to

network with other colleagues 67.5%(n=27), and obtain an additional quali-fication 27.5% (n=l 1). Parsons (1998)in Gary (2002:33), contends that em-powered health care professionals canperform their jobs more confidently andeffectively. Empowerment relates to thesense of self-worth and competencethat comes from having skills and abili-ties to carry out the required job, skillswhich are acquired through a processof continuing professional develop-ment.

The reasons agreed upon for engag-ing in continuing formal education arecongment with the findings of Eustace(2001:134), who reports that reasonsgiven for undertaking continuing for-mal education include: to enhance pro-fessional knowledge; advance profes-sionally and acquire credentials. Ehrat(2001:36-42), states that in most circum-stances, continuing professional devel-opment in nursing and the accompa-nying acquisition of leadership skillspositively correlates with improved,demonstrated technical and generalskills. This is affirmed by Hoban(2005:22), who emphasises that educa-tion allows the nurse to look at the widerissues around practice, and meetingpatients' needs more efficiently.

Motivation for engaging in continuingformai educationThe respondents were asked to re-spond to statements pertaining to whatwould motivate them to undertake aprogramme of continuing formal edu-cation (Table 2). The motivators forengaging in continuing formal educa-tion, given as a combination of agreeand strongly agree responses, were:prospects of promotion and remunera-tion 80% (n=32); assistance with work-ing out a career pathway 75% (n=30);ftinding assistance 72.5% (n=29); rolemodels who demonstrate the value ofcareer development 72.5% (29); recentsuccess in a study programme 70%(n=28); peer encouragement 67.5%(n=27); encouragement from manage-ment 62.5% (n=25); obtaining a SANCqualification with scarce skill allowance62.5% (n=25); and a study skills courseprior to commencement of a formal pro-gramme 62.5% (n=25). It appears thatapart from financial and promotionalmotivators, supportive stmctures inthe work environment such as assist-ance from management, peer encour-

agement and good role models also actas strong motivators. Nolan, OwensandNolan(1995:553), found individualmotivation as one ofthe most signifi-cant factors confributing to participa-tion in continuing professional devel-opment and added that it is easier toimplement change when employees arehighly motivated, the environmentalinfrastructure is supportive and thechange initiative is widely accepted asrelevant.

Benefits of continuing formaieducationThe questionnaire statements regard-ing the benefits of continuing formaleducation were applicable to the ma-jority ofthe respondents 85.0% (n=34).The respondents who had neveraccessed a programme of study sinceregistration 15.0% (n=6), were not ableto answer this question. A closed-ended question was stated - whetheror not respondents had benefited froma programme of continuing formal edu-cation. Respondents who concludedthat continuing formal education hadbeen beneficial 67.6% (n=23), weregiven the opportunity to elaborate inan open-ended question. The aspectsmentioned most frequently included:financial and promotional prospects(n=8); enhanced knowledge base(n=7); and the development of leader-ship skills (n=5).

Smith and Topping (2001:341-349) ex-amined the relationship between under-taking a post-registration nursingcourse and the perceived benefits tothe nursing practitioners. The per-ceived benefits were improved knowl-edge, improved care delivery, and pro-fessional development.

Barriers to continuing formaieducationInvestigating the barriers to continu-ing formal education could provide themeans to devising innovative meansto facilitate and foster a culture of life-long leaming. The results showed thatrespondents perceive the following asbarriers to engaging in continuing for-mal nursing education programmes(Table 3). Lack of frmding 70% (n=28);job responsibilities 67.5% (n=27); con-ditions attached to the granting ofstudy leave 62.5% (n=25); lack of em-ployer cooperation - eg. for funding60% (n=24); family and child care re-

47Curationis June 2010

sponsibilities 55% (n=22); lack of co-herent staff development plans by theinstitution 52.5% (n=21); lack of a sup-portive work environment 50% (n=20);and lack of opportunities for promo-tion 50% (n=20).

Eales(2001:2),Ferguson(1994:645-646),Kersaitis (1997:138) and Yuen(1991:1233), have described physicalbarriers to continuing formal education- those factors in the individual's lifecircumstances at any given time suchas lack of time because of job respon-sibilities; family and child care respon-sibilities; and difficulties in payingcotirse fees. Hoban (2005:23), pointsout that inadequate funding is a con-tentious issue and argues that healthinstitutions cannot afford to send staffaway for long periods of time as thereis no point in having highly trainednurses if there is no one left to care forpatients. However, to be empoweredis to have access to the information,resources and support necessary forcompetent patient care, and to have theself-worth that comes from having theskills and the ability to carry out therequired job (Gary 2002:34).

Structural barriers to continuing formaleducation referring to the practices,procedures and policies that place lim-its on opportunities for potential adultlearners, have been identified as lackof coherent staff development plans;difficulty in obtaining study leave; anon-inclusive style of nursing manage-ment; and lack of support from manag-ers (Leading learning and skills [LSC]2005:2-4; Penzetal 2007:59,60,62). Thelack of a supportive working environ-ment and lack of opportunities for pro-fessional growth are cited as deterrentsto continuing formal education. Somenurses feel that there is little space forthem to grow in their profession inSouth Africa, complaining about thelack of opportunities for promotion, thedifficulty in getting study leave, andnursing education not being subsi-dised, leading them to choose to emi-grate (Xaba and Phillips 2001:1 -7).According to Bester and Mouton(2006:51), employees must get sufficientopportunities to realise their ñill poten-tial and to experience job satisfactionandjob involvement. Jooste (2003:150)strongly supports this view by refer-ring to people as the greatest asset ofany organisation and states that they

must be cared for and valued as em-ployees and not manipulated.

ConclusionThe findings of this study revealed thatregistered nurses recognise the ben-efits of continuing formal education notonly for themselves but also for thepatients, as the main reasons providedfor pursuing continuing formal educa-tion were to keep abreast with devel-opments in areas of speciality and todevelop the necessary proficiency tomeet patients' needs. There was alsostrong evidence that the participantsin this study, the majority of them be-ing in senior positions (85%), want todevelop leadership capabilities and beeffective mentors for junior staff. Theplanning of career pathways and im-proving prospects of remuneration andpromotion, were indicated as reasonsbut also as the strongest motivatorsfor engaging in continuing formal edu-cation. The availability of ñinding andsupport within the work setting(through role models demonstrating thevalue of career development and en-cotiragement from peers and manage-ment), also seem to be strong motiva-tors for engaging in continuing formaleducation.

In this study the main barriers to con-tinuing formal education appear to bephysical barriers which refer to lack offlinding, job and family responsibilities;and structural barriers, which includeconditions attached to granting studyleave, lack of coherent staff develop-ment plans and opportunities for pro-motion, and lack of a supportive workenvironment. However, it does appearthat some institutions do have staffdevelopment plans, support their staffand provide opportunities for promo-tion as only 50% respondents indicatedthese as barriers. Recognition of thebarriers to continuing formal educationdemands a collective response from thehealth care institution, the individualnurse and the nurse manager in orderto overcome these barriers.To address the nurse's career goals,both organisations and individualsshould share responsibility for the ca-reers of employees. Nurses are likelyto have more successful careers if or-ganisations and individuals are in-volved in career planning and manage-ment. Plans have to be put in place bynurse unit managers and organisational

management to make provision in theirbudgets for registered nurses to accesscontinuing formal education pro-grammes.According to Hoban (2005:24), life-long learning should be about improv-ing patient care and service deliveryand the enhancement of inter-profes-sional practice. Ultimately it is the healthcare user, the health care profession andthe employing organisation that willbenefit from continuing education. Themore health professionals learn, themore they will challenge traditionalpractices, embrace change and fosterinnovation.

Limitations of the studyA limitation of the study was the re-sponse rate of 57% (n=40) which im-pedes the generalisation of the researchresults. Generalisation of the researchresults is fiirther limited because thestudy was conducted in only fourhealth care institutions. However, thereis both a possibility and a need for theresearch to be replicated in other healthcare institutions across other provincesin SouthAfrica.

RecommendationsThe following recommendations aremade:

• The majority of registerednurses in this study were in the46-55 year age range. The aver-age age the nurse in this studywas qualified was 21.15 years.The aging nursing work forceis a factor that nursing and or-ganisational managementwould do well to consider asthey plan strategies to retain ayounger mobile workforcethrough programmes of con-tinuing formal education whileensuring the older work forcemaintains relevancy in theirpractice.

• Organisations should create aculture of valuing continuingformal education and empha-sise the need for senior staff toact as role models in this re-spect. Nurses need to be moti-vated in a supportive environ-ment through the availability ofmanagerial positions, promo-tion opportunities and ñexiblework schedules.

48Curationis June 2010

• Health service managers andeducators should be aware ofthe need for adjustable, flexiblework and course schedules toaccommodate potential leamersand therefore consult with eachother with regards to the plan-ning of post-regisfrationcourses. Inflexible work sched-ules result in not having accessto professional growth oppor-tunities which is a factor influ-encing nursing staff tumover(Shader, Broome, Broome, West&Nash2001:211).

• Registered nurses should beencouraged to use their apprais-als as managers are obliged toidentify the nurse's leamingneeds, interpersonal develop-ment needs, and plan how theseneeds will be met.

• Combining specific j ob-relatedskills fraining with an individu-alised continuing formal educa-tion programme, drawn up dur-ing the annual performance re-view process, has the dual ad-vantage of showing staff howvalued they are as individualsand of equipping them to moveinto new roles in the organisa-tion (Hoban 2005:24).

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