University of Ghana http://ugspace.ug.edu.gh SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON EXPERIENCES OF PROFESSIONAL NURSES WITH CONTINUING PROFESSIONAL EDUCATION IN THE GREATER ACCRA REGION, GHANA BY IRENE BUTLER (10263176) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PHILOSOPHY DEGREE IN NURSING JULY, 2019 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION DECLARATION I, Irene Butler, do declare that this thesis is the result of my study undertaken towards the Award of Master of Philosophy Degree in Nursing at the School of Nursing and Midwifery, University of Ghana. This study has not been submitted to any other university or institution for any degree or diploma. IRENE BUTLER …………………… …………….... CANDIDATE) SIGNATURE DATE DR. ADELAIDE MARIA ANSAH OFEI ………………….. …………..…. (SUPERVISOR) SIGNATURE DATE MRS. ADZO ATSWEI KWASHIE ……………………. …………… (SUPERVISOR) SIGNATURE DATE i University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION ABSTRACT Continuing professional education is indispensable to the nursing profession. Rapid changes in health care delivery requires that nurses participate in continuing professional education in order to provide better care to patients. Nurses have the opportunity to participate in both formal and informal continuing professional education. The objective of the study was to explore the experiences of registered nurses with continuing professional education using the Cross chain of response model. The qualitative descriptive design was used. Participants in the study were selected using purposive sampling. Semi-structured interview guide was used to explore the experiences of participants. Analysis of data was done using thematic content analysis. The study was guided by four themes which were perception of continuing professional education, motivation to seek continuing professional education, barriers to continuing professional education and strategies to enhance participation in continuing professional education. The findings of the study indicate that nurses have a positive perception of continuing professional education. Participants were motivated by factors such as acquiring knowledge and skills, upgrading, renewal of professional lincence and social networking. Barriers to continuing professional education such as family responsibilities, high cost of fees, rigid schedules were identified by participants. Participants also suggested strategies such as review of policy on study leave, health facility strategies, nursing administration strategies and financial support. The recommendations of the study are continuing professional education should be included in the basic training of student nurses so as to sensitize students about the need to continue learning after basic training. All bodies responsible for organizing continuing professional education for professional nurses should do a thorough needs assessment to aid them in designing appropriate programs that will promote continuing professional education for nurses. ii University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION DEDICATION I dedicate this study to my late Grandmother Mrs Edwina Assan-Essuman. You were always proud of my achievements and inspired me to reach higher. I can imagine how proud you would have been of me now. iii University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION ACKNOWLEDGEMENT I am extremely grateful to my supervisors Dr. Adelaide Ansah Ofei and Mrs Adzo Atswei Kwashie for their valuable contributions, support and guidance without which this study would not have been possible. I am very grateful to my husband Reverend Lovell Ankrah whose unflinching support inspired me to complete this study. I also wish to acknowledge the Dean and all lectures of the school of Nursing and Midwifery, University of Ghana, Legon for your exemplary leadership and guidance. I am also extremely grateful to all the nurses who consented to be part of this study. I finally wish to acknowledge all the authors of the articles and books used for this study. iv University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION TABLE OF CONTENT Content Page DECLARATION........................................................................................................... i ABSTRACT .................................................................................................................. ii DEDICATION.............................................................................................................iii ACKNOWLEDGEMENT .......................................................................................... iv LIST OF FIGURES .................................................................................................... ix LIST OF TABLES ....................................................................................................... x LIST OF ABBREVIATIONS .................................................................................... xi CHAPTER ONE .......................................................................................................... 1 INTRODUCTION........................................................................................................ 1 1.1 Background to the Study ...................................................................................... 1 1.2 Statement of the Problem ..................................................................................... 4 1.3 Purpose of the Study ............................................................................................ 5 1.4 Objectives of Study .............................................................................................. 5 1.5 Research Questions .............................................................................................. 5 1.6 Significance of the Study ..................................................................................... 6 1.7 Operational Definitions ........................................................................................ 6 1.8 Organization of the Work ..................................................................................... 7 CHAPTER TWO ......................................................................................................... 8 LITERATURE REVIEW ........................................................................................... 8 2.0 Introduction .......................................................................................................... 8 2.1 Conceptual Framework ........................................................................................ 8 2.1.1 Application of the Model to Determine Experiences of Nurses ..................... 11 2.2 Perception of Continuing Professional Education ............................................. 12 v University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 2.3 Motivating Factors in Seeking Continuing Professional education ................... 14 2.4 Barriers to Continuing Professional Education .................................................. 17 2.5 Strategies to enhance continuing professional education participation ............. 20 2.6 Summary of Literature Review .......................................................................... 23 CHAPTER THREE ................................................................................................... 24 METHODOLOGY .................................................................................................... 24 3.0 Introduction ........................................................................................................ 24 3.1 Research Design ................................................................................................. 24 3.2 Research Setting ................................................................................................. 24 3.3 Target Population ............................................................................................... 25 3.3.1 Inclusion Criteria ............................................................................................. 26 3.3.2 Exclusion criteria............................................................................................. 26 3.4 Sampling and Sample size.................................................................................. 26 3.5 Data Collection Tool .......................................................................................... 27 3.6 Procedure for Data Collection ............................................................................ 28 3.7 Data Management .............................................................................................. 29 3.8 Data Analysis ..................................................................................................... 30 3.9 Methodological Rigour (Trustworthiness) ......................................................... 30 3.9.1 Credibility........................................................................................................ 31 3.9.2 Dependability .................................................................................................. 31 3.9.3 Transferability ................................................................................................. 32 3.9.4 Confirmability ................................................................................................. 32 3.10 Ethical Considerations: .................................................................................... 33 3.11 Summary of Methodology ............................................................................... 33 vi University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION CHAPTER FOUR ...................................................................................................... 34 FINDINGS OF THE STUDY ................................................................................... 34 4.0 Introduction ........................................................................................................ 34 4.1 Demographic Characteristics of Participants ..................................................... 34 4. 2 Organization of Themes and Subthemes ........................................................... 36 4. 3 Perception of Continuing Professional Education ............................................ 37 4.3.1 Acquiring knowledge and upgrading .............................................................. 37 4.3.2 Improvement of Skills ..................................................................................... 38 4.3.3 Exposure to New Trends ................................................................................. 38 4.4 Motivation to Seek Continuing Professional Education .................................... 39 4.4.1 Acquisition of Knowledge and Skills.............................................................. 39 4.4.2 Upgrading ........................................................................................................ 39 4.4.3 Renewal of Professional Licence .................................................................... 40 4.4.4 Social Networking ........................................................................................... 40 4.4.5 Higher Qualification of Colleagues................................................................. 41 4.5 Barriers to Continuing Professional Education .................................................. 41 4.5.1 Situational Barriers .......................................................................................... 42 4.5.2 Institutional Barriers ........................................................................................ 44 4.5.3 Dispositional barriers ...................................................................................... 46 4.5.4 Organizational Barrier ..................................................................................... 48 4.5.5 Facility Barrier ................................................................................................ 49 4.6 Strategies to Enhance Continuing Professional Education Participation ........... 52 4.6.1 Review of Policy on Study Leave ................................................................... 53 4.6.2 Health Facility Strategies ................................................................................ 53 4.6.3 Nursing Administration Strategies .................................................................. 55 vii University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 4.6.4 Financial Support for Continuing Professional Education .............................. 56 4.7 Summary of Findings ......................................................................................... 56 CHAPTER FIVE ....................................................................................................... 58 DISCUSSION OF FINDINGS .................................................................................. 58 5.0 Introduction ........................................................................................................ 58 5.1 Perception of Continuing Professional Education ............................................. 58 5.2 Motivating Factors in Seeking Continuing Professional education ................... 60 5.3 Barriers to Continuing Professional Education .................................................. 62 5.4 Strategies to Enhance Continuing Professional Education Participation ........... 67 5.5 Summary of Discussion ..................................................................................... 69 CHAPTER SIX .......................................................................................................... 71 SUMMARY, CONCLUSION AND RECOMMENDATION ................................ 71 6. 0 Introduction ....................................................................................................... 71 6. 1 Summary of the Study ....................................................................................... 71 6.2 Implications of the Research .............................................................................. 73 6.2.1 Implication for Nursing Practice ..................................................................... 73 6.2.2 Implication for Nursing Education .................................................................. 73 6.2.3 Implication for Nursing Research ................................................................... 74 6.3 Limitations of the Study ..................................................................................... 74 6.4 Insight Gained .................................................................................................... 74 6.5 Conclusion of the Study ..................................................................................... 75 6.6 Recommendations of the Study ......................................................................... 76 REFERENCE ............................................................................................................. 77 APPENDICES ............................................................................................................ 87 viii University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION LIST OF FIGURES Figure Page Figure 2. 1: Chain of Response Model ........................................................................ 10 ix University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION LIST OF TABLES Table Page Table 4. 1: Participants Demographic Data ................................................................. 35 Table 4. 2: Summary of Themes and Sub-themes ....................................................... 36 x University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION LIST OF ABBREVIATIONS CPE Continuing Professional Education NMC Nursing and Midwifery Council for Ghana PML Princess Marie Louise Children’s Hospital LEKMA Ledzokuku-Krowor Municipal Assemble GHS Ghana Health Service xi University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION CHAPTER ONE INTRODUCTION This chapter presents the background to the study and the statement of the problem as well as the purpose of the study, the objectives of the study, the significance of the study and operational definitions. 1.1 Background to the Study In present times, society is inundated with ever increasing knowledge and technological advancement, affecting all spheres of society and industry. Health care is not left out of this rapid advancement which has led to rapid changes in health care delivery. This trend has necessitated that health care professionals, deliver quality healthcare that meets the needs of clients. In order to render quality care, health care professionals must be dedicated to constant updating of professional knowledge, skills and practice. (Price & Reichert, 2017). Nurses who form the majority of healthcare professionals are thus expected to engage in continuing professional education in order to update, their knowledge and professional skills. Continuing professional education (CPE) is the process by which registered members of a particular profession maintain, update their knowledge and skills in order to remain competent in their profession (Ross, Barr, & Seven, 2014). Gallagher (2007) describes continuing professional education as a basic component of professionalism. According to Marzlin (2011) Continuing professional education is a self-directed activity that goes on throughout an individual’s career and helps the individual develop. Professionals are thus expected to be abreast in their practice by participating in continuing professional education in order to remain competent in their profession. Continuing professional education is used interchangeably in 1 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION literature with continuous professional development (Gopee, 2005; Hegney, Tuckett, Parker, & Robert, 2010). Continuing professional education benefits the professional by affording the professional the opportunity to meet standard requirements of providing ethical, competent and safe services. In the nursing profession continuing professional education equips nurses to adapt to the ever changing demands of the healthcare system. Continuing professional education also enables nurses to maintain and acquire new knowledge, skills and competence which ensures patients receive better care. According to Ispir and Duygulu (2017) continuing professional education leads to nurses employing current practices that are evidence-based resulting in shorter hospital stays and also leads to the retention of nurses. Nurses have the opportunity to participate in two forms of continuing professional education. These are formal continuing professional education and informal continuing professional education. Formal continuing professional education occurs in a formal setting with a structured academic program involving course work toward a diploma, degree, masters or doctorate (Fights, 2012). Whiles, informal continuing professional education occurs in forms such as, learning at the clinical area, part-time courses, workshops, conferences, seminars, e-learning modules. (Gopee, 2005; Price & Reichert, 2017). Formal and informal continuing professional education are interrelated. Informal learning culminates in formal learning and vice versa, both serve the same ends and thus demands equal attention (Smith, 2008). Participating in either formal or informal continuing professional education offers the nurse the opportunity to grow, remain relevant and effective to the profession. Current practice in most countries including Ghana mandates nurses to participate in continuing professional education in order to renew their professional 2 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION licence to practice. In these countries nurses are expected to partake in either formal or informal continuing professional education programs within a specified period in order to earn a predetermined number of points to qualify to renew their professional license. Mandatory continuing professional education is based on the premise that knowledge acquired from initial qualification into a profession is not enough to practice with throughout the life of the professional (Duţă & Rafailă, 2014). Changing trends in technology, disease and patient care require that for effective practice nurses consistently acquire additional knowledge throughout their professional life (Price & Reichert, 2017). Making continuing professional education mandatory therefore ensures that nurses will participate in an educational activity periodically. Continuing professional education is not well understood (Shagrir 2009), thus even though nurses are expected to participate in continuing professional education some nurses however do not. Particularly in Ghana this may be due to the way continuing professional education activities are introduced after initial training of nurses and the lack of coordination between the different continuing professional education programs that are organized. Even though continuing professional education is mandated the specific learning requirement that is needed by nurses to ensure they acquire needed knowledge and improve skills are not formally stated (Ross, Barr & Seven, 2013). This situation makes participating in continuing professional education non directional. Little is known about the experiences of nurses with continuing professional education. This study therefore seeks to explore the experiences of nurses with continuing professional education, what motivates nurses to choose a particular learning activity, the barriers nurses face and strategies that can be used to enhance continuing professional education for nurses. The study 3 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION will use the Chain-of-Response Model, by Patricia Cross (1981) which explains the decision of adults to participate in an educational program or not. 1.2 Statement of the Problem The Nursing and Midwifery Council (NMC) for Ghana mandates nurses to participate in continuing professional education every year in order to qualify for renewal of their professional licence. The NMC, however does not specify the content of the continuing professional education program. Nurses are only required to present evidence of learning which meets the required points demanded by the council to meet the requirement for licence renewal. Due to this several nurses take part in continuing professional education programs which may not be related to their current practice but because evidence can be shown of participation nurses are able to renew their professional licence (Ross et. al., 2013). This practice creates a situation where learning is taking place but may not necessarily have impact on the direct nursing care being given to patients. Additionally, even though continuing professional education is mandatory some nurses are unable to participate in continuing professional education due to barriers such as inadequate time, lack of finances, family responsibilities, in adequate staffing among others. (Teekens, Wiechula, & Cusack, 2018). Some nurses also find available continuing professional education programs irrelevant to their current practice (Badu-Nyarko, 2013). Therefore exploring the experiences of nurses with continuing professional education by seeking to understand their perception, motivation, barriers and preferred strategy to enhance their participation in continuing professional education will help to develop interventions that will lead to improving the relevance and quality of continuing professional education for nurses, which will ultimately enhance standards of nursing practice. 4 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 1.3 Purpose of the Study The purpose of this study is to explore the experiences of nurses concerning continuing professional education. 1.4 Objectives of Study The objectives of the study are to; 1. Explore the perception of nurses about continuing professional education. 2. Explore the factors that motivate nurses to seek continuing professional education. 3. Describe the barriers to continuing professional education among nurses 4. Identify strategies that can be used to enhance continuing professional education participation. 1.5 Research Questions The study was guided by the following research questions; 1. How do nurses view continuing professional education? 2. What motivates nurses to seek continuing education? 3. What are the barriers encountered by nurses when it comes to continuous professional education? 4. What strategies can be used to enhance continuing professional education participation for nurses? 5 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 1.6 Significance of the Study The outcome of the study will add to existing knowledge and serve as a reference for future research. The outcome will benefit the regulatory body, the Nursing and Midwifery Council for Ghana (NMC), the Ghana Health Service, as well as other agencies and individuals accredited by the NMC to organize relevant continuing professional education activities, to formulate strategies to improve continuing professional education for nurses. The findings of the study will also generate interest in the field of continuing professional education for other researchers. 1.7 Operational Definitions • Continuing professional education (CPE): this refers to additional formal or informal learning that takes place after a nurse has completed basic training. It lasts throughout the period the individual is practicing as a nurse. • Registered Nurse: this refers to an individual who has completed basic nursing education and has been licensed to practice. • Experience: practical knowledge, or skills gained from direct observation of or by participating in events or an activity. • Motivation: internal or external factors that stimulate desire and drive in people to be interested and dedicated to make an effort to accomplish a goal. • Barriers: a problem that stops people from doing something, or limits what people can do. • Strategies: a plan of action calculated to achieve a long term or overall aim. 6 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 1.8 Organization of the Work The study has been organized into six (6) chapters. The first chapter provides the background and highlights the problem statement of the study, the purpose of the study, objectives of the study, research questions, as well as the significance of the study. The second chapter focuses on the review of relevant literature on perception of nurses about continuing professional education and the theoretical framework guiding the study. The third chapter describes the research design and whiles the fourth chapter presents the findings of the study. The fifth and sixth chapter covers the discussion of the findings of the study, nursing implications, limitations, summary, conclusion and recommendation. 7 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter presents the reviewed literature related to the study and a review of the conceptual framework guiding the study. Literature review was done using different sources such as books, peer reviewed journals and the internet. Electronic databases used included ’Medline’, ‘Google Scholar’, ‘Science Direct’, ‘PUBMED’, ‘Sage’, ‘CINAHL’, and ‘HINARI’. Search terms used were the keywords “continuing professional education”, “continuing education”, “continuing professional development”, “professional development”. The keywords were used alone or by combining them in the literature search. The literature review has been organized in accordance with the objectives of the study. 2.1 Conceptual Framework This study used the Cross Chain of Response Model (Cross, 1981) to explore the experiences of nurses with continuing education. The researcher chose this model after reviewing other models on adult education. Force field analysis theory by Kurt Lewin (1977), expectancy-valence theory by Rubenson (1977), proficiency theory of adult learning by Knox (1980) these theories however rely heavily on motivation of the adult learner and does not address the impact of external barriers on adult learners. The Cross Model however, incorporates several learning theories and was appropriate to investigate the problem in this study because it focuses on different factors that have an impact on adult learners. The chain of response model determines why adults participate in a learning activity or chose not to. The model was appropriate for exploring the perception, motivation and barriers nurses encounter with participation 8 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION in continuing professional education programs. The Cross model represents a cycle that is made up of seven stages, which are seen as links in a chain. Each stage has their unique impact on the adult learner’s decision to participate in a learning activity or not. The different stages in the model are connected by arrows that reflect the interaction of the stages. The model begins with factors that relate to the adult learner and ends with external factors that affect the adult learner. Cross believed that participating in a learning activity, whether, in organized classes or self-directed is not a single act but an interaction of a chain of responses. The more positive an experience at each stage in the cycle, the more likely the adult learner is to reach the last stage (Cross, 1981). The stages in the model are (A) self-evaluation, and attitude of the learner towards education, (B) attitude about education, (C) the importance of the learner’s goals and expectation that participating in a learning activity will achieve, when motivations (D) life transitions, stages in the life of the individual, (E) opportunities and barriers that are associated with the learning activity, (F) information received on educational opportunities, (G) the learner’s decision to participate. 9 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION Source: Cross (1981) Figure 2. 1: Chain of Response Model Self-evaluation and attitude affects the learner’s perception of an educational program which in turn affects the goals and expectations that participating in an educational program will bring. Goals and expectations are influenced by life transitions. Life transitions are explained by Cross (1981) as a period of change in the learner’s life that calls for adjustments to be made, some agents that trigger these transitions are change of jobs, child birth, illness and divorce. These triggers can have a positive or negative effect on the learner. If the individual remains motivated, he or she moves to the next stage opportunities and barriers. Participation in an educational program is affected by the information the individual has on the opportunities available. The barriers are divided into three main groups; situational barriers, institutional barriers and dispositional barriers. Situational barriers are directly related to the individual such as family, time, and lack of money. Institutional barriers arise 10 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION from the institution organizing the learning activity, barriers such as inconvenient venue of educational activity, time classes or learning activities are organized and student support. Dispositional barriers relate to the learner’s perception of his or her ability to learn a particular subject or topic, lack of preparedness towards learning, feeling too old, attitude to being a student or being discouraged by a previous negative experience. The final stage, participation occurs when the potential leaner is able to overcome the first six stages in the cycle, after a successful participation in a learning activity the cycle begins again. After the learner has made the decision to participate in a learning activity, educational institutions and organizations should design strategies that will suit the student and facilitate learning. 2.1.1 Application of the Model to Determine Experiences of Nurses The Cross Chain of Response Model will be used to explore experiences of participants in this study with continuing professional education. The experiences of participants will be based on the assumption that adults who have participated in continuing professional education will be in a position to describe experiences. In this study perception about continuing professional education will be determined by the self-evaluation and attitude of participants to educational programs. The motivation of participants will be determined by the importance placed on goals and expectations of participates to engage in an educational program. Life transitions will however not be focused on in this study. Barriers to continuing professional education will be determined by situational, institutional and dispositional factors. Opportunities and information will not be focused on in this study. The study will then focus on strategies that can be 11 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION used to enhance participation in continuing professional education based on the barriers identified. 2.2 Perception of Continuing Professional Education Several studies have looked at the perception of nurses on continuing professional education and the influence it has on nurses’ participation in continuing professional education activities. (Altmann, 2012; Chong & Sellick, 2011, 2011; Flores Peña & Alonso Castillo, 2006; Govranos & Newton, 2014; Richars & Studies 2010). According to Gallagher (2006) nurses will be able to accept the idea of continuing professional education only if it is fully understood and made a part of the profession. An individual’s perception of continuing professional education affects the individual’s decision to participate in a particular continuing professional education activity or not. When nurses perceive a particular continuing professional education as important they are more likely to participate in it. (Brekelmans, Maassen, Poell, Weststratedr, & Geurdes, 2016). In majority of studies, both quantitative and qualitative, conducted across different countries, findings were that nurses had a positive perception of continuing professional education (Averlid, 2017; Brekelmans et al., 2016; Cotterill-walker, 2012; Flores Peña & Alonso Castillo, 2006; James & Francis, 2011). Nurses perceive participating in continuing professional education as essential to their practice. Engaging in continuing profession education leads to acquisition of knowledge. According to a study by Jiandani, Bogum, Shah, Prabhu and Taksande (2015) to assess the perceptions of healthcare faculty about Continuous Professional Development. the study found that all the participants (100%) were of the view that continuing professional education leads to knowledge acquisition, as well as change in attitude of health professionals (93.75%) towards patients. Participants also 12 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION strongly believed that continuing professional development helps to recognize knowledge gaps, and promotes self-reflection. These findings are confirmed by Nsemo, John, Etifit, Mgbekem and Oyira (2013) in their study to determine the perception of nurses on various aspects of continuing professional education, using a mixed method design. The researchers found that nurses had the perception that engaging in continuing professional education leads to the acquiring of new knowledge which equips nurses with current skills (Nsemo, John, Etifit, Mgbekem, & Oyira, 2013). Engaging in continuing professional education leads to improvement in the skills and competence of the nurse (Kamariannaki et al., 2017). In a study by Ni et al. (2014), involving 2,727 Chinese nurses fully employed in ten Chinese hospitals, the researchers set out to explore Chinese nurses’ perceptions on continuing education, the motivation and barriers nurses face when engaging in continuing professional education activities. The study found out that the nurses perceived continuing professional education important to nursing and as a means of improving their skills and competence. In a quantitative study by Price and Reichert (2017) to explore the role of ongoing training and education on nurses’ career satisfaction across different career stages and their ability to provide quality patient care. The study findings were that nurses expressed a strong interest in learning, perceived continuing professional education as a means of improving skills to provide quality care to patients. Continuing professional education leads to improvement in patient care. Légaré et al. (2017) in a study involving 376 health professionals in Canada, found that engaging in continuing professional education led to improvement in the quality of care given to patients. According to the study participants continuing professional 13 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION education led to the acquisition of new knowledge enabling the health professional to gain skills and provide better care to patients leading to better patient outcomes. However, some nurses have a negative perception of continuing professional education. In a study conducted in Jakarta, Indonesia, by Hariyati and Fujinami (2019) involving 149 nurses, one of the significant findings of the study was that nurses had a negative perception of continuing professional education. According to the researchers this negative perception was caused by nurses not having adequate knowledge on availability of continuing professional education learning activities. In a similar quantitative study by Chong and Sellick (2011) on what influences Malaysian nurses to participate in continuing professional education. The researchers discovered that some nurses did not participate in continuing professional education although it was mandatory. The reasons for non-participation was however, not elicited, hence, this study will have benefited from a mixed method approach which would have given the authors a clearer picture. The literature reviewed above shows that nurses’ have a positive perception of continuing professional education, as a means of acquiring knowledge, improvement in skills and competence as well as improvement in patient care. Some nurses’ however have a negative perception of continuing professional education. 2.3 Motivating Factors in Seeking Continuing Professional education Nurses are motivated to participate in continuing professional education programs due to various reasons, some of the reasons are for personal gain and others are for professional. According to Brekelmans (2016) the main motivation for nurses to participate in a particular continuing professional education activity is strongly dependent on how they perceives that particular activity and the importance that is placed on it. 14 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION Nurses are motivated to participate in continuing professional education due to self-motivation and for personal satisfaction. In a study in Croatia conducted by Kopacevic et al. (2013) the most important motivations for participating in continuing professional education identified by participants in the study were to improve knowledge, improve self-confidence, and maintaining clinical competence. In a qualitative study by Zahran (2012) to find out the motivation of nurses to study at the graduate level and their perception of how it will affect their practice. The study findings were that nurses were motivated by self-development, expanding their opportunities for career development, and developing practice. According to Macaden et al. (2017) some nurses are also motivated to participate in continuing professional education due to a personal interest in learning itself. The intrinsic motivation of nurses to develop themselves in other to remain competent and abreast with the requirements of their profession shows a good prognosis for giving quality care to patients. Acquisition of knowledge and skills have also been found to be a motivating factor in literature (Chong & Sellick, 2011; Kopacević, Bozan Mihelcić, 2013). In a study by Burrow (2016) to understand the motivations and experiences of health and social care professionals undertaking part-time, accredited, continuing professional education in higher education. One of the discoveries of the research was that nurses participated in continuing professional education for knowledge and skills acquisition. Watkins (2011) in his study discovered in addition to knowledge and skills nurses were also motivated by colleagues who were ahead academically. Pursuing formal continuing professional education was a motivation for nurses who didn’t want to be ‘left behind’. 15 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION Nurses are further motivated to participate in continuing professional education to increase their skills and competence. Pool, Poell, Berings and Ten Crate (2016) undertook a study with the aim of exploring the relationship between nurses' motives and activities for continuing professional development. Qualitative data was collected from twenty one nurses in the Netherlands. The major finding of the study was that the major motive for nurse’s engaging in continuing professional education was to increase knowledge. Other motivating factors were to renew professional license, for promotion and to acquire knowledge. Nurses acquire new skills from participating in continuing professional education which increase their competence and leads to the nurse becoming more confident. Fulfilling minimum requirement for re-licensure is another motivating factor. In separate studies conducted in Ghana, (Badu-Nyarko, 2013) and Nigeria, (Nsemo et al., 2013) participants identified renewal of professional license as the most important factor for engaging in continuing professional education. Both studies also identified acquisition of skills and improved competence as a motivating factor. In both countries continuing professional education is mandatory for nurses. According to Pool, Poell, Berings and Ten Crate (2016) mandatory requirements from regulators is a strong motivating factor for nurses to participate in continuing professional education. Several other literature identified mentorship and support from employers as a motivating factor to participate in continuing professional education (Adeniran, Smith-Glasgow, Bhattacharya, & Xu, 2013; Averlid, 2017; Doerksen & Cnn, 2010; Drey, Gould, & Allan, 2009). In a quantitative study by Katsikitis (2013) to ascertain the current understanding, practice and future continuing professional development needs of nurses and midwives employed in a regional area of Queensland, Australia, 16 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION the major findings were that nurses preferred education to occur within work hours, and approximately two-thirds of participants believed continuing professional development should be shared between them and their employers. In addition, peer attitude, sharing and support are motivators that bring positive practice change (Lee, 2011). Nurses are also motivated to engage in continuing professional education when there is available funding provided by the employer for the continuing professional education activity (Kopacević, Bozan Mihelcić, 2013). According to Nsemo (2013) nurses will however not show interest in a continuing professional education program if it will not lead to increase in salary. Another motivating factor identified for engaging in continuing professional education are to build a professional network (Pool, Poell, Berings, & Ten Crate, 2015). In a study by Saade, Ghazala, Farhat and Hallit (2018) to assess the perception, motivation and attitudes of pharmacists in Lebanon to mandatory continuing education. One of the study findings were that pharmacists were motivated to participate in continuing professional education due to opportunities for networking and socializing with other colleagues. 2.4 Barriers to Continuing Professional Education Motivation to participate in continuing professional education can be hindered by the barriers that the individual encounters after the decision to participate in continuing professional education has been made. From the Cross model (1981) barriers to continuing professional education can be grouped under three broad headings, situational barriers, institutional barriers and dispositional barriers. Situational barriers are obstacles that are related to circumstances surrounding the individual at a particular time in the individual’s life. Lack of finance to attend 17 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION continuing professional education programs is a situational barrier that has been identified by several studies (Badu-Nyarko, 2013; Nsemo, 2013; Chong & Sellick, 2011). Being unable to pay to attend continuing professional education programs hinders the participation of nurses. A strong drive to engage in continuing professional education may exist but without adequate funding intention to learn may have to be postponed or cancelled. Time constraints also acts as a barrier to participating in continuing professional education. Insufficient free time due to busy work schedules acts as a barrier to most health professionals (Cook, Price, Wittich, West, & Blachman, 2017; Dean, 2004; Gopee, 2005; Hegney et al., 2010; Norushe, Van Rooyen, & Strumpher, 2004). Although health professionals may be willing to participate in particular learning activities more often than not they do not get the opportunity due to inadequate free time (Bindon, 2017). As such planned learning activities may have to be canceled at the last minute because schedule of the health worker can change suddenly (Averlid, 2017). Another noted barrier to participating in continuing professional education activities is due to nurses working in environments where there is inadequate staffing. Inadequate staffing leads to excessive workload resulting in nurses not having sufficient time to participate in continuing professional education programs. A study using the grounded theory approach by Feldacker, Jacob, Chung, Nartker and Kim (2018) involving 89 health workers spanning three African countries Malawi, Tanzania and South Africa. The researchers discovered that the main barrier to continuing professional education was lack of sustainable financial support, limitations in coordination in continuing professional educational programs and healthcare worker shortages. Due to staff shortage, some nurses are not able to find 18 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION replacements should they leave the work area to participate in continuing professional education activities. Another barrier is family responsibilities. According to Ross et. al. (2013) some nurses are unable to create a balance between their work, family responsibilities and continuing professional education and this results in the nurse not being able to participate in continuing professional education programs. Finding adequate care for children is a barrier that prevents nurses, majority of whom are females from participating in continuing professional education. Institutional Barriers are barriers that arise from institution or groups that organize continuing professional education (Cross, 1981). Distance acts as a barrier to continuing professional education activities. Some continuing professional education activities are organized far away from where the nurse’s work and this affects their ability to attend. (James & Francis 2011; Ross 2013) and as such nurses may not able to participate in continuing professional education activities due to difficulty in accessing the learning resources because the venue maybe geographically far from the location of the nurse (Baxter et al., 2013). Incivility by educators at institutions of learning also acts as a barrier. In a study by Small, English, Moran, Grainger and Cashin (2018) using a sectional design to examine incivility in nursing academia from the perspective of 380 baccalaureate nursing students the findings indicated that majority of the students thought incivility was present in nursing education and ranged from mild to moderate, lectures were authoritarian, used in-effective teaching methods, were disrespectful and lacked compassion. Other barriers identified in literature are tiredness and difficulty in concentrating after work, personal commitments, inflexible time schedules, disinterest 19 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION in the topic being taught, negative experiences from previous learning programs, inadequate programs, lack of variety in courses offered, poor planning by educational institutions, and inappropriate teachers (Eslamian, Moeini, & Soleimani, 2015; Summers, 2018). Venue barrier has been indicated in literature as a barrier. In a study conducted in Nigeria by Nsemo et al. 2013, findings of the study revealed that (81.3%) of participants were of the view that continuing professional educational programs were not suited to the needs of learners, according to the study (58%) of participants preferred continuing education programs organized outside the facility to avoid distractions and enhance concentration, whiles (42%) preferred those organized in the facility. Dispositional barriers prevent the adult learner from participating in continuing professional education. Dispositional barriers relate to the adult learner’s attitude and perception of education. Richards and Potgieter (2010) posit that bad experiences with previous education leads to dispositional barriers. Negative experiences may lead to the nurse not desiring to return to school. According to the authors dispositional barriers cause nurses to develop low self-esteem and uncertainties about continuing professional education. 2.5 Strategies to enhance continuing professional education participation Learning are needs are specific to an individual and can be identified by that individual through engaging in a specific activity or through experience (Norman, Shannon, & Marrin, 2004), thus the gap between the current knowledge and skills of a nurse and what he or she needs to know and the skills he or she needs to acquire determines her choice of continuing professional education. For the uptake of continuing professional education to be effective among health care professionals, 20 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION learning needs must be taken into account and used when planning continuing professional education activities. (Doerksen & Cnn, 2010), as well as their preferred learning strategies. Planning of continuing professional education activities should be carried out systematically, the problem should be identified, appropriate plans to solve the problem planned with nurses, then it should be implemented and evaluated. Additionally, in a study by Pool, Poell, Berings and Ten Cate (2015) the researchers stated that, the needs of different groups of nurses must be taken into account, as nurses of different ages have different learning needs. According to them older nurses were not interested in CPE due to their rich experience, whiles nurses who were younger seemed more interested in CPE. Furthermore, the authors stated that CPE should be geared towards younger nurses as the majority of nurses are young and are still searching for what they really want to do or become in life, whilst adult nurses may be narrow - minded because they might have already created a niche for themselves. The use of technology has been suggested as a means of making continuing professional education. Primmer (2014) suggests the use of mobile phones and social media as a means of creating learning environments, mobile phones can be used as a tool for disseminating information and used as a systematic way of learning. Obtaining paid leave from employers has been suggested as a way to enhance participation in continuing professional education (Burrow, Mairs, Pusey, Bradshaw, & Keady, 2016; Chong & Sellick, 2011; Ni et al., 2014; Thomas, Jinks, & Jack, 2015). When employers provide study leave with pay motivation to participate is increased. Online courses have also been suggested as a means of enhancing continuing professional education. Due to various barriers of continuing professional education 21 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION such as time and family responsibilities, assessing courses on line has been suggested as an alternative to going away to school, online learning is done at the convenience of the learners and offers different learning opportunities (Feldacker, Jacob, Chung, Nartker, & Kim, 2018; Giri et al., 2012). Seven, Cinar, Fidanci and Akyuz (2014) in a descriptive study in Turkey involving 238 nurses to assess nurses’ attitudes towards graduate distance education in nursing. A major finding of the study was that more than 50% of the participants were of the opinion that distance education would be easier for nurses to participate in than current education available, the participants however concerned about lack of role models and feedback from learning as nursing is a practice-oriented profession. According to Bjørk, Tøien, and Sørensen, (2013) opportunities for informal learning at the clinical area rests on nurse managers of wards, whose actions must be that of role models in order to promote learning on the wards. Organizational support offers strong motivation for nurses to engage in continuing professional education programs, such organizations are viewed in a positive light by nurses (Adeniram et al., 2013; Bindon, 2017; Katsikitis, 2013). In a study by Clark, Draper and Rogers (2015) to identify the processes that key stakeholders perceive to be most important in facilitating a positive impact of continuing professional education on practice. Researchers discovered that organizations that are supportive and encourage learning offer strong motivation for nurses to engage in continuing professional education programs, such organizations are viewed in a positive light by nurses. 22 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 2.6 Summary of Literature Review This chapter presented the literature review and conceptual framework which guided the study. The literature was presented in line with the objectives of the study. The literature showed that nurses had differing views of continuing professional education. Some perceptions were to acquire knowledge and skills, exposure to new trends and improvement in patient care. Some of the motivations for seeking continuing professional education were due to self-motivation, personal satisfaction, acquisition of knowledge and skills as well as to fulfill requirements for re-licensure. The literature also focused on the barriers to participating in continuing professional education. Some of the barriers identified in literature were inadequate time, lack of finances and family responsibilities. Several strategies were also identified by the literature search such as facilities creating a culture of learning, the use of online, weekend and distance learning. 23 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter presents the study’s methodology which includes the research design, research setting, target population, sampling and sample size, data collection, data analysis, data management, measures of ensuring methodological rigour, and ethical consideration. 3.1 Research Design This study employed the exploratory descriptive design, using the qualitative approach. A descriptive qualitative study is an in-depth summary of actual events experienced by individuals or a group of individuals. (Dash, 2018). This type of design was appropriate for this study which was aimed at exploring the experiences of nurses about continuing professional education. It enabled in-depth views of the nurses to be elicited. This enabled the researcher to understand and describe in detail the perception, motivation, barriers and strategies available to the participants. 3.2 Research Setting The study was conducted at the Princess Marie Louise Children’s Hospital, in the Greater Accra region of Ghana. The Princess Marie Louise (PML) Children’s Hospital is located in the heart of Accra, in the Ashiedu Keteke district. It is the first ever children’s hospital in Ghana, the hospital was built in 1926 to cater for the needs of maternal and child health care delivery with a total bed capacity of one hundred and four (104). It is the only one out of the four district hospitals in Accra, which provides healthcare solely to children. 24 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION PML serves patients in the Greater Accra region, as well as from other regions in Ghana and neighboring countries such as Togo and Ivory Coast. The facility renders several services including medical, surgical, child health clinics, family planning, and nutrition services. It has a dental unit, an Eye Unit, as well as an Ear, Nose and throat Unit. It has wards for in-patients, an out-patient department, a pharmacy, laboratory department, radiology, nutrition unit, neonatal intensive care unit, theater, recovery ward and mortuary. The hospital also runs several clinics at the out-patient department every week, such as the sickle cell clinic, asthma clinic, neuro- developmental disorders, and malnutrition disorders. The total number of professional and non-professional nurses at the facility are one hundred and six (106), and the number of professional nurses seventy-eight (78). The researcher chose this setting because Paediatric Nursing is an area of interest to the researcher, who has worked in a Paediatric settings for many years. The hospital also has professional nurses of all categories, who will get opportunities to engage in both formal and informal continuing professional education. Thus, different experiences of continuing professional education can be explored. 3.3 Target Population The target population are the total group of people from which a sample can be drawn. (Tracy, 2013). The target population for this study were all professional nurses working at the PML children’s hospital. 25 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 3.3.1 Inclusion Criteria The study included; 1. Professional Nurses with at least three years working experience, 2. Should have participated in any form of formal CPE activity. 3. Should have participated in at least two (2) informal CPE activities 4. Should consent to participate in the study. 3.3.2 Exclusion criteria 1. The study excluded professional nurses with less than three years working experience. 2. Professional nurses with three years’ experience who had not taken part in any formal CPE activity and had participated in less than two informal CPE activities. 3. Professional nurses who declined to participate in the study were also excluded. 3.4 Sampling and Sample size Purposive sampling technique was used to select participants who were considered to be knowledgeable, met the inclusion criteria and were willing to participate in the study. Purposive sampling is a method in which the researcher selects study participants on the basis of personal judgment about which ones will be most representative (Polit & Beck, 2003; Zimmer, 2006). The final sample size was determined during data collection when data saturation was confirmed by the 10th participant as no new ideas were obtained. The sample of a qualitative research is dependent on when saturation is reached, when participants give responses that are alike and no new themes or sub themes arise. 26 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION According to Farrokhi and Mahmoudi-Hamidabad (2012) data saturation occurs when newly collected data does not yield any new idea. 3.5 Data Collection Tool A semi-structured interview guide was used. This tool was used because it is not rigid and also allows the researcher to probe into specific areas of interest. (Seidman, 2006; Tracy, 2013). The guide was based on the objectives of the study and literature. The interview guide was reviewed by a qualitative research expert to verify its contents. The interview guide was in two sections. Section A of the interview guide focused on the demographic information of the participants, whiles section B consisted of four main open–ended questions with probes. The first question focused on perception of nurses on continuing professional education, the second question centered on the motivation to continuing professional education, whiles the third question was directed at the barriers and opportunities to continuing professional education. The final question centered on the strategies that can be used to enhance continuing professional education. The interview guide with open ended questions enabled the researcher to gain in-depth information from participants and also allowed the researcher to probe further in order to know what is important from the point of view of the participants (Hays, 2006). The developed interview guide was pretested with some selected professional nurses at the Ledzokuku-Krowor Municipal Assemble (LEKMA) hospital that had similar characteristics as the participants in the study. The interview lasted between 30-60 minutes per participant. 27 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 3.6 Procedure for Data Collection The researcher sought permission from the Medical Director and the Nurse Manager of Princess Marie Louise children’s hospital with an introductory letter from the School of Nursing and Midwifery, University of Ghana, as well as the two ethical clearance obtained for the study. After permission was granted by the Medical Director for the research to commence the researcher met the Nurse Manager who assisted the researcher to select participants for the study. The researcher recruited and conducted interviews over a period of five weeks. Interviews were conducted in the senior nurses’ office on the second floor of the hospital. Participants were recruited from the first and second floor, out-patient department (OPD), eye clinic and the Neonatal Intensive Care unit (NICU). The purpose of the study was explained in full to the participants to gain their cooperation. During the recruitment session, the information sheet was also given for further clarification on the research topic. Participants who were willing to participate in the study were given the consent form to sign, ensuring their willingness to participate in the study. A convenient time and venue was then arranged with each participant for the interview to be conducted. The second-floor ward in-charge granted permission for the interviews to be conducted in her office. The researcher ensured that the audio recorder was in good condition and fully charged for each interview period. Permission was sought from participants to record the interview session. Before the interview commenced, the researcher established rapport with the participants to relieve anxiety by talking generally about continuing professional education. The interview began with “what does continuing professional education mean to you?” and this opened up discussions as the participants shared their perceptions. Responses that were unclear were clarified whenever necessary 28 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION while asking for follow-up information during the interview, probes were used where necessary. The researcher used a field diary to take brief notes in order to keep track of ideas for later exploration while observing for verbal and nonverbal behaviors of participants. As the data collection and analysis progressed, the researcher discovered more about the participant experiences with continuing professional education. Thus the researcher focused on the issues and ideas significant to the participants rather than the concepts that she had considered as essential before beginning the study. At the end of the interview session, the researcher played back the recorded interview to the participants to verify information given. Interviews were transcribed exactly as stated. Data analysis was done alongside the data collection. Saturation was reached by the tenth participant as no new ideas on the topic was brought up. 3.7 Data Management After data collection, the researcher had to familiarize herself with the data by listening to the recorded interviews several times in order to understand it and make meaning out of it. The audio data was then transcribed verbatim. Recordings from interviews as well as transcribed interviews for each participant were numbered and given pseudonyms for anonymity and stored on a password protected Personal computer and, in the cloud, (Google drive), which is only accessible to the researcher. Recordings will be destroyed after five years from the time the study is completed and accepted. Printed transcribed interviews as well as field notes were kept under lock and key. Additionally, the demographic characteristics of the participants were kept separated from the hard copies. 29 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 3.8 Data Analysis NVivo version 12 was used to organize the data obtained after transcribing. Data analysis was done alongside the data collection using thematic content analysis. (Lin, 2009; Seidman, 2006; Tracy., 2013). Thematic content analysis enhances the representation of verbal expressions in a contextual form, while maintaining the main ideas irrespective of the volume of data involved. It also involves the process of identifying coding and categorizing primary patterns found in the data collected (Hsieh & Shannon, 2005; Polit & Beck, 2010). In order to use the thematic content analysis, the transcribed data was read several times to gain better understanding. Data that were considered as irrelevant was put aside but not discarded as they may be of use to the researcher later. After the initial coding the data was exported into NVivo to start creating codes. The main codes were given labels that represented the objectives of the study. At this stage the transcripts were reread several times to gain further understanding. Codes that did not appear to fit into the themes and sub-themes were noted. Emerging sub codes were placed under the appropriate main codes, categories were created merging codes that were similar. Relationships between the different categories created were compared. Themes were identified, which related to all the data and then discussed with supervisor(s) to have a better data analysis. 3.9 Methodological Rigour (Trustworthiness) To ensure rigour of the study, the researcher used Lincoln and Guba (1985) criteria for ensuring rigour of the study. Lincoln and Guba proposed four criteria for ensuring the trustworthiness of a qualitative research, which are credibility, dependability, transferability and confirmability. 30 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 3.9.1 Credibility Credibility in a qualitative research is achieved when the findings in a research reflect exactly what the participants perceive of a phenomenon (Lincoln & Guba, 1985) . To achieve credibility in this study, the researcher collected data over a period of five weeks until saturation was reached (this was realized when no new information was brought up). The researcher recruited only participants who met the inclusion criteria and these participants were able to give information that portrayed their experiences with continuing professional education. Rapport was established with participants. This ensured that trust was built and participants could open up and share their perceptions. Participants were also assured of confidentiality of the information given. During the interview session open ended questions and probes were used to elicit detailed information from the participants. Member checking was done by restating some of the information given by participants during the interview and also playing the audio recording at the end of the interview session for the participants to verify, in order to ensure that true responses were documented (Birt, Scott, Cavers, Campbell, & Walter, 2016). The researcher frequently engaged her supervisors regarding the research methodology and data collecting procedures to guide the work. Pretesting of the tool was also done to test the effectiveness of the interview guide. 3.9.2 Dependability Dependability refers to the extent to which research findings can be repeated among same sample or context. (Lincoln & Guba, 1985; Marquart, 2017). To ensure dependability in the study a comprehensive account of each stage of the process involved in conducting the study was described. Developing an audit trail helps external reviewers to ascertain the study’s dependability. Through this another 31 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION researcher can equally replicate successfully the research using the same process (Marquart, 2017). The data collection process was explained and duration of data collection was also stated. All field notes, audio-recordings and transcriptions aided in presenting the exact view of the participants thus increasing the dependability of the study. 3.9.3 Transferability Transferability in a qualitative research can be met when the outcome or findings of the study can fit into another similar context (Lincoln & Guba, 1985). Transferability was achieved by providing a detailed description of the research process for the study. The researcher also gave adequate description of the research participants, stating the inclusion and exclusion criteria of the participants. The researcher additionally, provided detailed description of the topic under study in order to aid the reader’s understanding and application of the findings of the research to similar situations. 3.9.4 Confirmability Confirmability refers to the extent to which a research finding reflects the experiences of participants and is devoid of researcher bias (Polit & Beck, 2003). In order to achieve confirmability the researcher sought for in-depth experiences of professional nurses on continuing professional education and not that of the researcher. The researcher applied bracketing. The researcher did this by ensuring that her notion about continuing professional education as a nurse did not influence the findings of the study. The researcher explained in detail her decision for choosing the specific research methodology guiding the research. Finally, the researcher verified from the participants whether the transcribed data represented their ideas. 32 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 3.10 Ethical Considerations: Ethical clearance was obtained from the institutional review board of the Noguchi Memorial Institute for Medical Research, University of Ghana, Legon and Ghana Health service, institutional review board. After clearance was given, along with introductory letter from the School, permission was sought from the Medical Director and Nurse Manager at the Princess Marie Louise children’s hospital. The participants were informed that they could opt out of the study anytime they wished despite signing the consent form. No form of coercion was used to attract or retain them. Participants were made to demonstrate consent to participate in the study by signing consent forms. The participants were also informed that each interview session will be audiotaped and that they were free to answer or not answer the questions put to them. Participants were assured of confidentiality as to information given and their identity. During data analysis identities of the participants were protected through the use of pseudonyms. There were no risks involved in participating in the study and no cost was incurred by participations in the study. 3.11 Summary of Methodology This study used a qualitative exploratory approach. A purposive sampling technique was used to select participants for the study within the target population who met the inclusion criteria. Data was collected and analysed after ethical considerations were met, methodological rigour was ensured and consent given by participants. 33 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION CHAPTER FOUR FINDINGS OF THE STUDY 4.0 Introduction This chapter covers the findings that were generated from the data collected from the participants in this study which set out to explore the experiences of Nurses with continuing professional education in the Greater Accra region. The findings have been organized into themes which are in harmony with the Cross Chain of Response Model (Cross, 1981) and the objectives of the study. The main themes, emerging themes and sub-themes are presented using verbatim quotations from the study participants. 4.1 Demographic Characteristics of Participants Ten (10) participants were interviewed for this study. All ten (10) were females. The age range of participants was between twenty nine (29) to thirty nine (39) years; with a modal age of twenty nine (29) years and an average age of thirty four (34) years. Six of the participants were married whilst four were single. The participants who were married had at most three children. The years of experience of participants ranged between five (5) to sixteen (16) years. All ten participants had completed at least one formal education and partaken in at least two informal education (workshops). Out of the ten (10) participants, two (2) had certificates in Paediatric Nursing, the remaining eight (8) of the participants had a first degree, seven with a Bachelor of Science in Nursing and one (1) with a Bachelor of Science in Public Health. Out of the eight (8) with first degrees, only two (2) certificates had been officially recognized by the Ghana Health Service, the other six (6) certificates 34 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION had not being recognized and one (1) held Masters in Advanced Nursing practice. Summary of demographic characteristics are presented in table 4.1 Table 4. 1: Participants Demographic Data Pseudo S ex Age Place of Marital No. of Qualification Years of name (years) Residence Status Children work Experience N1 Female 36 Sarpeiman Married Three (3) Diploma in Fifteen (15) Nursing years BSc Public Health Nursing N2 Female 39 Osu Married Three (3) Diploma in Fifteen (15) Nursing years Certificate in Paediatric Nursing N3 Female 36 Accra Married One (1) Diploma in Ten (10) years Central Nursing BSc Nursing N4 Female 39 Kuntunse Single None Diploma in Sixteen (16) Nursing years ENT Nursing certificate BSc Nursing MSc Advanced Nursing practice N5 Female 29 Ashaley Single None Diploma in Five (5) years Botwe Nursing BSc Nursing N6 Female 32 Dzorwulu Single One (1) Diploma in Ten (10) years Nursing Certificate in Paediatric Nursing N7 Female 29 Kasoa Married One (1) Diploma in Five (5) years Nursing BSc Nursing N8 Female 34 Agege Married None Diploma in Eight (8) Nursing years BSc Nursing N9 Female 31 Ofankor Married One (1) Diploma in Nine (9) years Nursing BSc Nursing N10 Female 29 Dansoman Single None Diploma in Six (6) Nursing BSc Nursing Certificate in Paediatric Nursing 35 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 4. 2 Organization of Themes and Subthemes Four (4) themes, two emerging themes and their corresponding subthemes were derived from the interviews conducted after thematic content analysis. These themes and subthemes are presented in figure 4.2. Table 4. 2: Summary of Themes and Sub-themes THEMES SUB-THEMES Perception of CPE 1. Acquiring further knowledge and upgrading 2. Improvement of Skills 3. Exposure to New Trends Motivation to seek CPE 1. Acquisition of knowledge and skills 2. Upgrading 3. Renew Professional license 4. Social Networking 5. Higher qualification of colleagues Barriers to participation in CPE Situational barriers 1. Family responsibilities 2. Inadequate time 3. High cost of fees Institutional barrier 1. Rigid schedules 2. Poor treatment of the adult leaner 3. Choice of venue 4. Choice of facilitator Dispositional barrier 1. Negative experiences Organizational barrier • Challenges with study leave Facility barrier • Late Notice • Shortage of staff • Unfair selection process Strategies to Enhance CPE 1. Review of Policy on study leave 2. Health facility strategies 3. Nursing administration strategies 4. Financial support for CPE 36 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 4. 3 Perception of Continuing Professional Education Perception of adult learners influences the individuals’ attitude towards learning and their intention to pursue a particular education or decide not to participate. This theme described how nurses perceive continuing professional education. Three sub- themes emerged from the data. The sub-themes were acquiring further of knowledge and upgrading, improvement of skills, and exposure to new trends. 4.3.1 Acquiring knowledge and upgrading Acquiring knowledge is a way by which people learn and upgrading means moving from one stage to a higher stage. Majority of the participants in the study were of the view that continuing professional education lead to the acquisition of knowledge and upgrading of the nurse. Participants had this to say: “It means acquiring more knowledge and upgrading in your area of work. For example, going to school to learn pediatric nursing is continuing professional education.”[N2] I regard continuing professional education as a way to upgrade ourselves and improve on our knowledge about things going on in our profession. [N3] “I think it is gaining more knowledge into the profession. For instance after the diploma, when you do the degree you learn new courses you didn’t do during the diploma, so it adds up to your knowledge.”[N9] “Continuing professional education is a means by which nurses gain knowledge and upgrade. Some of us may have completed school three, four years ago. And being on the ward all this time we need to upgrade ourselves”. [N6] “I think continuing education has got to do with gaining more knowledge and upgrading ourselves as nurses from time to time.” [N7] 37 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 4.3.2 Improvement of Skills Improvement of skills is an ongoing process in continuing professional education and has to do with sharpening old expertise or learning new abilities. Participants in this study perceived continuing professional education as a means of improving professional skills and what nurses do which helps them to give better care to patients. N1 was of the opinion that: “Continuing professional education improves upon what you do, it is acquiring new skills based on your profession, and it helps you to be better or a better skilled person who can give quality care to patients.” N10 also emphasized N1’s statement by saying; “I think it enhances your professional skills as a nurses and everything about what you do which helps you to give better care to patients”. 4.3.3 Exposure to New Trends When nurses engage in continuing professional education they are exposed to new trends in patients care. New trends are new developments in patient care. Participants were of the view that continuing professional education was a way of gaining exposure to new trends in the profession. They were of the view that the nurse could stay abreast with new trends that constantly come up by participating in continuing professional education. Participants stated that; “I know that continuing professional education is getting to know the new trends that are coming up in the profession, when you participate you become abreast with new trends.”[N4] “A lot of changes keep coming up every day on how we should care for patients. So when nurses are involved in continuing professional education they will be able to learn these new trends in order to offer better care to patients”. [N8] 38 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 4.4 Motivation to Seek Continuing Professional Education Motivation drives an individual to achieve a goal, target or dream. Motivation can be intrinsically generated by the individual or may be from external influences. The participants in this study were motivated intrinsically to seek new knowledge and skills. They were also motivated extrinsically, by the need to renew their professional licence, networking and colleagues who had upgraded. Five sub-themes emerged from the data on motivation to seek continuing professional education. The sub- themes were acquisition of knowledge and skills, upgrading, renewal of professional license, social networking and higher qualification of colleagues. 4.4.1 Acquisition of Knowledge and Skills For all the participants the main motivation they had for seeking continuing professional education was to gain knowledge, and sharpen skills. Gaining new knowledge and skills from participating in continuing professional education added to the confidence of the study participants, in themselves and their ability to give quality care to their patients. Participants stated that; “I take part in continuing professional education for knowledge. A nurse who has knowledge on what she is doing and the rational for doing it is self-confident.” [N10] “My motivation is to gain knowledge, so that alone motivates me, to gain knowledge and make sure my skills are sharpened.” [N1] 4.4.2 Upgrading Participating in formal continuing professional education programs gives nurses the opportunity to be promoted. Participates in the study were motivated to engage in continuing professional education to upgrade themselves. Participants stated that; 39 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION “I was motivated to participate because I wanted to upgrade myself. I had a diploma and I wanted a degree because I cannot stay at the same level forever.” [N3] “I am motivated to participate in continuing professional education in order to upgrade myself.” [N8] 4.4.3 Renewal of Professional Licence Some participants were motivated to participate in continuing professional education in order and to renew their professional licence. Participating in continuing professional education ensures nurses get a certificate which they can use to renew their professional licence. Participants stated that; “I partake in continuing professional education to renew my professional licence. We are told to renew our licence every year so whenever I attend a workshop I see it as an opportunity to do so.”[N5] “When I attend a workshop I am able to use the certificate to renew my professional licence, which is very important.” [N7] 4.4.4 Social Networking Participants also identified meeting new people and developing relationships with them as a factor that motivated them to participate in continuing professional education. Attending continuing professional education programs offered an opportunity for participants to meet and network with nurses from other facilities. N4 had this to say; “I participate in continuing education to meet with other people, to get connected to people. Networking, meeting other people exposes you to different ideas.” Additional incentive for participating in continuing professional education programs is that participants can connect with others who may be able to offer help in the future. N1 had this to say; 40 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION “Participating in some continuing professional education programs actually open doors for you. You meet other people from other facilities, you can meet some facilitators who are influential people, and they can actually help you with one thing or another in future. So I think personally it’s good that I take part. Getting to know other people and what they do from other facilities is also important.” 4.4.5 Higher Qualification of Colleagues Participants were also motivated to participate in continuing professional education by colleagues with higher academic qualifications. Participants who had been motivated by seeing their colleagues advance academically had this to say. “When I see my friends climbing the academic ladder, I am motivated to also further my education. If they can do it, I can also do it.” [N3] “When a colleague does something, maybe a course or something it motivates you to go higher. In a society where there is no competition everyone will be where they are. At least someone should do something that will motivate you to go higher.” [N4] “Where my colleagues are, in terms of their level in education motivates me, most of them have masters and I have one colleague who even has a PhD now. How can I be satisfied with a mere diploma? I also want to go further.” [N5] 4.5 Barriers to Continuing Professional Education Barriers are challenges that prevents individuals from doing something or limits what people can do. Barriers to continuing professional education prevents or stops the learner from participating in continuing professional education programs. Barriers to continuing professional education have been placed into three categories according to the Cross chain of response model (Cross, 1981). The three categories are situational, institutional and dispositional barriers. 41 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION In addition to these three barriers which were in-line with the Cross model, participants also identified additional barriers, which were organizational barrier and health facility barrier. 4.5.1 Situational Barriers Situational barriers arise from the personal situation of the individual which affects the individual’s participation in a learning program. Participants identified family responsibilities, inadequate time, high cost of fees and lack of financial support as situational barriers. i. Family Responsibilities Participants mentioned responsibilities of family such as pregnancy, taking care of children and parents as barriers that affected their participation in continuing professional activities of their choice. Participants had this to say; “I remember when I was pregnant with my second child i had by then gained admission to a school. But, when I realized that I was pregnant I deferred from the program and some years after her birth, I went back to school.”[N1] “Someone to take care of my children was a problem for me before I went to do the Paediatric course. I wanted to go to school but I had no one to look after my children so I had to forget about school for a while. I was afraid of leaving my children without proper care”[N2] “My mother is sick and that is a burden on me and affects my participation in continuing professional education”. [N8] ii. Inadequate Time Inadequate time was also identified as a major barrier by participants. Participants expressed interest in participating in continuing professional education but stated that they had only one day off in a week and using that time to attend a workshop was difficult. Participants said; 42 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION “Time, I do not have enough time, we have one day off at work and we close by late afternoon. What time will I get home? I have only one day of to wash and do other chores at home. I cannot use my day off to attend workshops and training programs.” [N6] “I do not have enough time to myself and that affects my participation in continuing education. The duty roster is prepared in such a way that it makes it difficult for you to get the time to go for workshops. There some workshops which are not organized by the Ghana Health Service, for, those workshops you have to pay in order to attend. But you will not be given any time off from work to attend these workshops you will have to use your day off. Even if I was willing to use my day off to attend a workshop, what happens when the workshop is more than one day? I cannot attend.” [N3] “For me the main barrier that affects my participation will be the time factor. Sometimes, I want to attend some of these workshops but I do not have enough time to myself. I only have one day of and I have other things to do at home. Deciding to use my day off to attend a workshop becomes difficult.” [N10] “My day off is the only free time I have to myself. I cannot use my free time to attend a workshop.” [N8] iii. High Cost of Fees The fees for formal continuing professional education are usually high. Participants identified High cost of fees as a barrier to their participating in continuing professional education. N6, stated that; “The fees was a problem, I had to pay six thousand Ghana cedis to do the course and the ministry told the facilities to sponsor us and they opted to pay half. During the program we found out that some facilities did not send representatives because they couldn’t sponsor their staff to come.” N9, also stated that: “Cost is a huge problem that is affecting my participation in continuing professional education. I want to pursue a Master’s in Public health next year but the cost of the program is high.” For informal continuing professional education, the story was similar. “With the informal continuing education, the workshops we attend, sometimes we have to pay I believe if you are going to 43 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION learn and the hospital will benefit, they should support, at least they should pay half. Some are expensive, so imagine my salary, how much is it? I can’t go.”[N5] “The cost involved is a problem for me, I know some workshops are not expensive, but sometimes we hear of it in the middle of the month and attending may affect your budget for the month because you haven’t planned it. . “ [N10] 4.5.2 Institutional Barriers Institutional barriers arise from educational institutions. Institutional barriers affect the learner negatively and may block the learner’s drive to learn (Cross, 1981). Institutional barriers arise from difficulties that learners encounter from institutions, organizations or individuals that organize learning activities. Institutional barriers arising from data collected on experiences with formal continuing professional education were; rigid schedules, poor treatment of adult learners, and for informal continuing professional education choice of venue and choice of facilitator were identified. i. Rigid schedules According to participants schedules for learning in academic institutions were rigid and did not favour those who had to work and school thus, making learning a challenge. N5 had this to say concerning schedules. “The time table at the school was too rigid, we had no free day. It was a major challenge”. N3 added that: “They know some of us are workers, but there is no consideration to make our time table more flexible, if you can’t make it, who cares?” “Sometimes, your shift at work can change suddenly maybe because someone is sick. I remember one time my in-charge had to change 44 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION my shift because of staff shortage at work but when I informed the lecturer that I couldn’t come for the class she said there was nothing she could do.” [N6] “The time table was not flexible at all. Personally I struggled a lot because I had to deal with different responsibilities at the same time. I was always under pressure.” [N10] ii. Poor Treatment of Adult Learners Some participants indicated that they were not treated as adults, and their grievances were not attended to promptly by authorities of the educational institution. “Well, the authorities did not have time for us the distance students as compared to the regular students. They treated us like senior high school students. Even when it came to our results, we will have to complain for a long time before our grades are posted.” [N5] iii. Choice of Venue Informal continuing professional education are either organized on the premises of health facilities or at venues outside health facilities. Whiles some participants in the study viewed workshops organized in the facility as a barrier, others viewed those organized outside the facility as a barrier. Participants who viewed workshops organized outside the health facility as a barrier stated that; “The workshops organized at the facility are better than those organized outside. I don’t know if it is because the facility is organizing it and they are making sure things are done the right way.” [N7] N9 added that workshops organized in the health facility was more convenient as compared to those organized away from the health facility. She stated that; “I prefer workshops that are organized here in PML, they are more convenient, you can come to work and still go for the workshop, even if you’re a bit late, you can still get in. But if they 45 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION are having the workshop outside the facility, you may have to leave there and come for afternoon or night duty which is cumbersome. Distance becomes a problem”. Conversely, some participants however viewed workshops organized inside the health facility as a barrier to their participation. N5 stated that; “For those workshops organized outside the hospital, because we are paying for it, they do it strategically. There are no distractions from patients and colleagues with workshops organized outside. I am able to concentrate and mostly they are of higher rank, than those organized in PML.” iv. Choice of Facilitator Participants preferred teaching to be done by external facilitators rather than internal facilitators, stating that because the short comings of the internal facilitators were known, it made accepting what they taught difficult. “For those workshops organized here, when the facilitators are nurses from other facilities, we seem to take the workshop more seriously, than when the facilitators are from the facility. I think when the facilitators are from outside it is better, because the nurses from the facility we know their conduct and they may not be serious. She may always be someone who is always late for work and she is standing there telling you to do something, you will not take her serious. For the external facilitator, you do not know where she is coming from and all that. For some of the internal facilitators we know they do not do what they say.”[N6] “With the workshops I know the facilitators here, they are my colleagues. Sometimes, what she knows I also know, so what is the essence of me sitting to listen?”[N5] 4.5.3 Dispositional barriers Dispositional barriers are barriers that relate to the leaner’s attitude, perception of him or herself as well as previous negative experiences and pressure of combining work and school. The sub-theme negative experiences explain this theme. 46 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION i. Negative Experiences Negative experiences have a negative impact on the learner deciding to pursue further learning. Most negative experiences arose from participants who worked and schooled at the same time. N8 had this to say: “In fact, most of us regretted we did Paediatrics. We were told we would be upgraded and after school it took a long time. There was a whole lot of heddles. I had a bad experience”. N3, who had not been grated study leave, even though she was due, had this to say: “I applied for study leave after seven years of service and I couldn’t get it. So I had to come for night duty, be squeezing myself and attending. It was very stressful, because one, I have a family, two, my work, three other personal issues, it is very stressful.” N4, the only participant who holds both a first degree and a Master’s degree none of which have been recognized by Ghana Health service, because she pursued them without study leave, had this to say: “It wasn’t easy, it was very hectic, the BSc for instance, I close work… lectures start at two, and we close late 9:00 pm and sometimes I get home around 11 pm, we sometimes have a lot of assignments to do. You may end sleeping around one or two am when you get to work in the morning, you’re always tired. You look so tired every day.” N7, who pursued a BSc in nursing, after three years of service, when she was not due for study leave, stated: “The experience was a lot of ‘wahala’, because I had to work and school. I got the opportunity to school, but, I wasn’t due for study leave so I didn’t even apply for it, I knew I would have to work and school. Basically, I run night shift, I attended on weekends. It was difficult for my family but we pulled through by God’s grace.” 47 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 4.5.4 Organizational Barrier Participants identified challenges with study leave as an organizational barrier. According to participants challenges arose from the Ghana Health service, the employer. Participants faced difficulty in being granted study leave, even when they were due. Some participants were considering moving out of the clinical area due to this barrier. i. Challenges with Study Leave Participants lamented that gaining study leave was difficult, it took a long time to be granted study leave because there may be others ahead who had not been granted study leave yet more often than not a person may be due for study leave but will not be granted study leave due to the queue. “You have to wait for quite a long time before being granted a study leave especially with getting study leave to pursue a degree, getting a study leave is very difficult [N9] “You have to wait if it is a long queue before you will be granted study leave to school”. [N1] “Ghana health service queue? I don’t trust Ghana Health service queue. I know people who have served for seven years and they have not been granted study leave because there is a long queue. I don’t see why anyone should choose to wait all these years before being granted a study leave” [N5] According to participants if an individual decided to pursue formal education without study leave the certificate acquired will not be recognized by the Ghana health service. N6 had this to say; “The Ghana Health Service regional office, will not grant you the study leave and if you school without it, your certificate will not be recognized. Right now I have completed a BSc in nursing, when I get my certificate I will still not be upgraded because I schooled 48 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION without study leave. Despite, the fact that I was due for study leave but because of a long queue I was not granted.” Some participants expressed the desire to move out of the clinical area, as they felt frustrated with the challenges faced with acquiring study leave. Participants stated that; “I want to leave the clinical area. I feel limited. Getting study leave is a problem. When you get the certificate without the study leave the certificate will not be recognized. So what should we do? Clinical nursing is frustrating, they are frustrating us.” [N8] “I am thinking of resigning, if I am not given the chance to further my education because when you are working you won’t be given the chance to go to school. You won’t get study leave and we are many in the system. I have gotten the opportunity to go for a year and come back, so I don’t think I will get that opportunity again. Unless I want to do it privately and the course I want to do is a regular one, there is nothing like an evening school, or a weekend school, it is a fulltime course, so I will have to leave work to pursue it”. [N6] 4.5.5 Facility Barrier Participants identified the management of the health facility as contributing to the challenges they face in pursuing continuing professional education. Three sub- themes explaining facility barrier were late notice, shortage of Nurses’, and unfair selection process. i. Late Notice Participants lamented that they did not receive information concerning continuing professional education on time and this affected their participation. They claimed that the nursing administration deliberately withheld information concerning workshops from them until the last minute. Participates shared their concerns; “The nursing administration usually withholds letters to workshops, till the last minute. We have families and 49 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION responsibilities and it becomes difficult adjusting at the last minute.” [N8] “Sometimes, you don’t get the message early, you can probably get it two or three days to the workshop and you can't attend because you’re not prepared.” [N10] “We don’t get to hear about the workshop on time. The last workshop I attended I hadn’t planned it. [N7] ‘The nursing administration always tell you late. So, sometimes, arranging your family, getting someone to take care of them becomes a problem and then you are not able to attend a particular workshop” [N1] Participants also claimed that at other times, they did not receive the information at all, information concerning some continuing professional programs were not disseminated to everyone, only those selected to attend were informed about it. Participants stated; “You will not even get to know, you only hear, that there is a workshop and people have gone already, and you would say, oh, I would have liked to go”. [N4] “How will you hear of it? You won’t hear of it, if you are not chosen to go, you won’t hear of it.” [N3] “Currently, there is a workshop going on at Kumasi, I was looking for a colleague only for somebody to tell me, ‘oh, she called me that she was going for a workshop at Kumasi’ (laughs) really? We are in this hospital and we don’t even know that a workshop is going on?”(Laughs) [N2] ii. Shortage of Staff According to participants, there are instances when they are willing to pay and attend workshops, but, due to shortage of staff, gaining permission to attend becomes a difficulty. Participants had this to say; “It hasn’t been palatable, because you hear of a workshop somewhere and you want to go with your own money but you are not given the chance to go because of staff shortage. So sometimes even though you want to use your own money you can’t go and that is not been good.” [N2] 50 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION “You may want to pay to attend a workshop but if your in- charge says well, if I allow you to go there will be shortage then you can’t go”. [N10] “You will not be sponsored and you want to sponsor it yourself to attend a workshop which will help you work better and they say shortage of staff don’t go.” (Laughs). [N3] “Sometimes, you may have planned to attend a workshop but you may have to change it last minute because there may not be enough people on duty when the time arrives and you cannot leave the ward and go”. [N10] iii. Unfair Selection Process Participants bemoaned the way the selection to attend continuing professional activities was done. According to participants, if an individual is not selected by the nursing administration they cannot take part in continuing professional education activities. They were also of the view that favorites were always selected, the same people were always chosen and some nurse managers who were mainly involved in administrative duties attended workshops that younger ones who were actually working should attend. Participants lamented that; “The nursing administration selects those who will go, if you are not chosen by the nursing administration how can you go? They select those they like so if they don’t like you, forget it” [N3] “Someone goes for every workshop and there are some who throughout the year have not gone for any workshop. What kind of arrangement it that? But who are you to talk? It is the nursing administration that will choose, so, if you’re not chosen, you can’t go”. [N10] “The same people are sent over and over again to attend workshops. The nurses who work here are many. The same people should not always go for workshops. Others should also be given the chance to attend workshops.” [N7] Some participants lamented that they had not been chosen to attend a workshop outside the facility in a long while. N5 stated that: 51 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION “The last workshop I attended was on hand washing and it was organized by this facility that is why I had the opportunity to attend (raises voice) I don’t remember the last time I was selected to attend a workshop outside this facility.” [N5] According to N6 she got the opportunity to pursue her certificate program because she had been someone’s favorite. She had this to say: “When it comes to study leave we are given quotas. When I was going to school they chose ten people from Greater Accra. So everybody chose their favorites. On the ward I was, people showed interest, some had worked longer than I had, I had worked for two years. I was someone’s favorite. I was even on leave when I was called. So favoritism is present.” Whiles, the unfair selection process has led to feelings of anger in some, in others it has led to a feeling of apathy and unconcern. Participants expressed their feelings; “I really get angry, I get furious. I have complained several times about the bias way people are selected but, at the end of the day nothing happens.” [N4] “A feeling of apathy and remaining unconcerned, whatever happens nobody cares, if I come, I do the little I can do, I go my way. Selecting favorates to always attend workshops brings apathy. [N9] 4.6 Strategies to Enhance Continuing Professional Education Participation Participants suggested several strategies to enhance participation in continuing professional education, such as Ghana Health Service reviewing their policy on study leave, health facility strategies, nursing administration strategies and provision of financial support. 52 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 4.6.1 Review of Policy on Study Leave Participants suggested that the Ghana Health Service should remove embargoes on study leave, allow facilities to grant study leave, reduce the number of years before being granted a study leave and accept the certificates of those who were due and had acquired formal education without study leave. “Ghana health service should remove embargoes on study leave. The face of health in Ghana can change totally through continuing professional education so they should remove those measures that prevent us from learning”. [N8] “The service should increase the study leave quota, this big region, how can you give only ten people study leave in a year? Number of years to work before being granted study leave should also be reduced, if you have to work for six year before getting the chance for formal education, it is not the best”. [N1] “Ghana health service should do something about how they grant study leave, do they really want us to learn? If my facility can release me then, I should be granted. Choosing only ten people to grant study leave every year for the Greater Accra region is too small”. [N7] N10 also added that: “Ghana Health Service should accept the certificates of those of us who have been able to further without study leave. Some us were due but were not granted study leave.” 4.6.2 Health Facility Strategies According to participants the facility should lobby for more staff and the Ghana Health service should also employ more nurses, in order to make access to continuing professional education possible. External facilitators should be brought to teach for internal workshops, nurses’ should be allowed to choose topics that interest them and needs assessment should be conducted before planning learning programs. 53 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION “In the first place I think this facility, should lobby for more staff, because our shortage is too much, if we lobby for more staff, then the facility can take it upon itself to allow staff go for continuing professional education. Especially, those who are willing to sponsor themselves” [N1] “The Ghana Health service, should employ adequate staff so they can allow people to pursue their education. [N3] For workshops organized at the facility participants suggested that, external facilitators be brought to teach and workshops should be organized quarterly. Participants stated; “If a workshop is being organized in this facility, the facility can bring in external coordinators to make learning more effective”. [N6] “PML should bring in external facilitators, we don’t want people form PML that we know and workshops should be organized for us every quarter.”[N4] Participants also requested that they be allowed to choose topics of interest to them “For informal continuing professional education we should be allowed to choice topics we are interested in”. [N6] Additionally, N1 stated that in-service coordinators should do a problem analysis before bringing up topics and informal continuing professional education should be organized every three months. “With the informal learning programs, I think the in- service coordinator or facility should also come up with a problem analysis and find out what the nurses actually need to be trained in and they should make it mandatory that every three months they are training on a particular topic at the facility.” Participants also suggested that external organizers of informal continuing professional education should send information on planned programs to the in-service coordinator, to be disseminated to the nurses. N8 suggested that; 54 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION “At the beginning of every month the information on workshops that they have planned should be send it to the in-service person so that we can get it.” 4.6.3 Nursing Administration Strategies Participants also suggested that there should be a policy ensuring that every nurse takes part in at least one informal continuing professional activity every year, the nursing administration should keep proper records on all those who attend a workshop to avoid sending the same people always and information concerning continuing professional education disseminated early. Participants stated that; “If there is a policy that every staff will participate it at least one workshop in a year which will be enforced. And it should be such that this time it is your turn, another time someone’s turn, then at the end of the day everybody will get his or her share. If there is nothing like that then the favorites will always go and the big bosses who will not practice will always go”. [N2] “They should record the people who go for workshops so that everyone will get a turn and not the same people going”. [N4] “There should be a schedule, so that if this person goes, it will be another person’s turn to go at another time. So that you can anticipate that for example in March I will be attending a workshop, so that you will not be called at random.” [N6] Participants also suggested that nursing administration should disseminate information continuing professional education programs early. Participants had this to say; “The nursing administration should bring the information concerning learning opportunities early”. [N6] Nursing administration should bring the information early so we can prepare, they shouldn’t wait till the last minute. [N2] 55 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 4.6.4 Financial Support for Continuing Professional Education According to participants the Ghana Health Service should put measures in place to support nurses’ not only by granting them study leave but also supporting them financially. Participants also suggested that the Health facility should also support nurses financially in order to enable nurses participate in continuing professional activities successfully. Participants suggested that; “Ghana health service should put measures in place so that we are not only granted study leave, but supported financially to pay our fees, maybe they can pay part and we pay the other part”[N10] ”The facility should do a yearly budgeting for continuing professional education, because you can’t work without thinking of the human resource. It is never done anywhere, even though there is no money you can still budget. Just as we have a Needy fund in this hospital for patients, we can have a fund for continuing professional education. Rather, the mind set of management is on patient, patient, patient and the one who is taking care of the patient is not considered”. [N2] ”If the facility pays for me to school, I don’t see anything wrong with it, I am not saying they should pay for everything, at least some” [N3] 4.7 Summary of Findings The study used the Cross chain of response model and four objectives that were in line with the model to explore the perception of registered nurses in the Greater Accra region. The perceptions of ten (10) participants were obtained after the objectives of the study had been explained to them. A semi-structured interview guide was used to elicit information on the topic. The interviews were recorded and 56 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION transcribed verbatim and the data obtained was analyzed using thematic content analysis. The findings of the study showed that the nurses had a positive perception of continuing professional education and were of the view that continuing professional education was important to the nurse. The participants also had the perception that engaging in continuing professional education lead to the acquisition further knowledge and upgrading, improvement in skills and exposure to new trends. The participants in the study were also motivated by several factors to engage in continuing professional education, such as, acquiring more knowledge and skills, upgrading, renewal of professional incense, social networking and higher academic qualification of colleagues. Participants however, faced several barriers to participating in continuing professional education. Participants mentioned barriers such as inadequate time, family responsibilities and challenges with study leave. Two emerging themes were identified; organizational barrier and facility barrier. Participants also suggested several strategies that can be used to enhance their participation in continuing professional education, participants gave suggestions such as Ghana Health Service reviewing their policy on study leave, receiving information from nursing administration on time, and receiving financial support from the facility to engage in continuing professional education. 57 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION CHAPTER FIVE DISCUSSION OF FINDINGS 5.0 Introduction This chapter discusses the major findings of the study in connection with related literature reviewed. The aim of the study was to explore the perception of professional nurses on continuing professional education. The discussion has been organized in accordance with the objectives of the study and Cross’ chain of response model. References to existing literature are made throughout the discussion in order to situate the research findings within the context of the body of nursing knowledge. 5.1 Perception of Continuing Professional Education Perception of adult learners influences the individuals’ attitude towards learning and their intention to pursue a particular education or decide not to participate (Cross, 1981). The findings of this study suggests that participants have a positive perception of continuing professional education. They were of the view that continuing professional education was important to nurses, the facility and employer, this finding can be related to previous studies across different continents, using both quantitative and qualitative methods that acknowledged that nurses found continuing professional education important (Averlid, 2017; Brekelmans et al., 2016; Cotterill- walker, 2012; Flores Peña & Alonso Castillo, 2006; James & Francis, 2011). This finding shows that nurses know the value of continuing professional education and perceiving it as important suggest that they are likely to participate in it. 58 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION Participants were further of the view that participating in continuing professional education leads to the acquisition of knowledge and upgrade of the nurse. This view was in line with the study by Jiandani, Bogum, Shah, Prabhu and Taksande (2016) who indicated in their findings that nurses were of the perception that engaging in continuing professional education leads to acquisition of knowledge and change in the attitude of the nurse. This finding suggests that nurses know that current knowledge can become obsolete and they knew of a means to upgrade their knowledge. Participants knew that by engaging in continuing professional education they will acquire new knowledge which will help them work better. However in the study by Hariyati and Fujinami (2019) nurses had a negative perception of continuing professional education due to nurses not having adequate knowledge on available continuing professional education learning activities, organizers of continuing professional education in Ghana should therefore ensure that nurses receive up-to-date information on continuing professional education programs. Participants were also of the perception that participating in continuing professional education lead to the improvement in the skills of nurses and what they do in order to provide better care to patients. This finding was compliments that of Kamariannaki et al. (2017) and Ni et al. (2014) who acknowledge that nurses perceive continuing professional education as a means of improving their skills and competence. This finding suggests that nurses are aware of the need to improve upon their skills and competence in other to give better care to their patients. Participants in the study were also of the view that participating in continuing professional education leads to nurses being abreast with new trends which are constantly emerging. This finding was in line with that of (Nsemo et al., 2013) who concede that nurse perceive participating in continuing professional education as 59 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION facilitating them to be up to date with current trends in giving care. This finding suggests that the participants in this study nurses are more likely to participate in continuing professional education as they saw it as a means of discovering new trends in nursing care. This perception held by participants suggests that nursing care of patients is likely to improve as more nurses seek continuing professional education in order to be abreast with current practices. 5.2 Motivating Factors in Seeking Continuing Professional education Participants in this study were motivated to participate in continuing professional education due to various reasons. Acquiring knowledge and skills was a motivating factor for participant in this study. This finding was line with Burrow (2016) and Chong and Sellick (2011) who state in their findings that nurses were motivated to engage in continuing professional education in order to update their knowledge and skills in order to provide better care to patients. This finding suggests that nurses desire to gain new knowledge and skills so as to provide better care to patients. Participants were motivated to participate in continuing professional education in order to upgrade professionally. This finding was in agreement with Zahran (2012) according to the findings of the research nurses were motivated to engage in continuing professional education for self-development, expanding opportunities for career development and to develop practice. Nurses’ motivation to better themselves and develop in their careers also supports the fact that nurses have a positive perception of continuing professional education. As career development leads to increase in salary nurses are more likely to participate in continuing professional education (Nsemo et al. 2013). 60 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION Participants in the study were also motivated to engage in continuing professional education in order to meet requirements for re-licensure (Badu-Nyarko, 2013; Nsemo et al., 2013). This finding validates the rationale behind making continuing professional education mandatory for nurses. Nurses are likely to engage in further learning so as to renew their professional license. This motivation ensures that the nurse will engage in continuing professional education leading to better patient care. Although any motivation to learn must be viewed in a good light, motivation to learn because it is mandatory can lead to nurses selecting learning activities which are not related to their current practice in order to gain certificates to renew their license leading to no impact on patient care. Another factor that motivated participants in this study to engage in continuing professional education was networking and socializing with other nurses. This finding is in line with motivations identified Saade, Ghazala, Farhat and Hallit (2018) who discovered in their study that pharmacists were motivated to participate in continuing professional education due to opportunities for networking and socializing with other colleagues. Organizers and facilitators of continuing professional education must then take this into account when planning programs and allow participates enough time to socialize. Socializing with colleagues will also lead to peer learning. Participants also indicated that they were motivated by colleagues who had higher academic qualifications this finding was in line with (Lee, 2011). This motivation can be harnessed by employers who want to encourage learning in their facilities by encouraging nurses to pursue education to the highest level that they are able, as this will in-turn encourage others to also aspire to the same heights. 61 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 5.3 Barriers to Continuing Professional Education Barriers to continuing professional education which is the central concept of the Cross model (Cross 1981) can prevent the adult learner from pursing continuing professional education. Identifying these barriers can help to devise strategies to alleviate it. Participants identified family responsibilities as a barrier. Participants stated that pregnancy, lack of child care and responsibility for parents was a deterrent to participating in continuing professional education. This finding is consistent with the study by Ross (2013) which indicated some nurses were unable to participate in continuing professional education due to family responsibilities. Organizers of informal continuing professional education programs and educational institutions must be conversant with these barriers that adult learners face and encourage nurses to participate by making lessons more flexible. Nurses with family challenges may also benefit from counselling on how to manage responsibilities and still participate in continuing professional education. Facilities should also take into account situational barriers of individual nurses before assigning them to particular continuing professional education programs, taking into account, distance, cost and time involved. Participants also identified inadequate time as a barrier to participating in continuing professional education. This finding is consistent with several findings (Cook et al., 2017; Dean, 2004; Gopee, 2005; Hegney et al., 2010; Norushe et al., 2004). In this study participants lamented that they had one day off in a week and using this day of to participate in a continuing professional education program was difficult. The health facility should consider nurses workload, working hours and days 62 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION off in order to make allowances where possible so as to encourage nurses to participate in continuing professional education. Participants also identified high cost of fees and lack of support by the facility as a barrier to their participation. Participants expressed a desire to pursue continuing professional education programs but stated that they were deterred by the cost involved. Lack of funding and inadequate support has been identified in literature as a barrier (Badu-Nyarko, 2013; Nsemo, 2013; Chong & Sellick, 2011). Barriers to of cost can be addressed by health facilities supporting nurses financially in their pursuit of learning. Educational institutions can also make payment of fees more flexible. Organizers of informal learning programs should also disseminate information concerning upcoming programs early to enable nurse’s plan adequately. Institutional barriers are those barriers that exist at educational institutions. Participants in this study stated that some of the barriers they faced were rigid schedules. Time tables were not flexible and thus not favorable to those working and schooling at the same time, this finding is consistent with (Eslamian et al., 2015; Summers, 2018). Institutions and organizers of learning programs must make time tables more flexible taking into consideration the responsibilities of adult learners. Time tables should also not be changed without the consent of the adult learner. Institutions must take into consideration that adult learners are likely to have varied responsibilities and may thus need to work and school. Thus, changing of education time tables without notice can be very stressful for the adult learner who may not be able to adapt to the change on short notice. Institutions or organizations that are not conscious of the needs of the adult learner may end up creating barriers that prevents students from pursing further studies. 63 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION Some participants further claimed that they were not treated as adults by authorities of educational institutions, their concerns were not addressed, this finding was consistent that of (Eslamian et al., 2015; Summers, 2018). Institutions should offer conducive environments that promote learning by encouraging and supporting leaners enrolled in their institutions, ensuring that adults are given the needed respect and encouragement they need to learn. Choice of venue was another barrier identified by participants in this study. Whiles some participants preferred having continuing professional education programs in the facility others preferred a venue further away from the facility this finding was consistent with that of Nsemo et al. (2013). Venue for informal continuing professional education should therefore be varied with these preferences in mind. Nurse Managers should also take this into account when selecting nurses to attend continuing professional education programs so that nurses can experience both the programs organized in the facility and those outside thus creating variety and preventing boredom. Facilitators are resource persons that teach at workshops or conferences, majority of facilitators for continuing professional education for nurses are professional nurses themselves. Facilitators may be chosen from among nurses at the facility to teach particular topics. Participants in the study however stated that they preferred facilitators who was not known to them rather than to their own colleagues at the facility. This was because they felt flaws in the character of fellow colleagues affected their ability to accept what was being taught, facilitators outside the facility however were not known to the nurses and participants felt they could receive more easily what was taught. Health facilities and organizers of informal continuing professional education programs should ensure that facilitators are not selected only 64 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION based on their being experienced in an area but also facilitators who are qualified to teach and are able to use a variety of appropriate teaching methods are selected. For major learning programs the facility should select facilitators from outside the facility to mitigate this barrier. Negative experiences when participating in a learning activity affects the learner’s perception of future studies and may sometimes lead to a drop out of the leaner (Cross 1981). Most of the negative experiences’ participants experienced were related to those who had to work and school at the same time. Educational institutions and health facilities can assist nurses by providing counseling on appropriate courses and by helping nurses select the most appropriate programs that will fit their individual needs to school and work. Participants also identified organizational barrier of challenges with study leave. Some participants claimed that even when they were due for study leave, they were not granted study leave. This finding built upon the finding by (Badu-Nyarko, 2013; Nsemo, 2013; Chong & Sellick, 2011). Generally, participants had issues with the mode of selection of those granted study leave and thus did not trust the selection process by employers. This finding suggest that some nurses have lost hope in the system and had no trust that they will gain study leave that was their due, this can perhaps explain why some participants were so frustrated that they were considering resigning from the Ghana health service with others considering moving away from the clinical area where they felt their need to learn was being stifled. Ghana Health service, the employer must as a matter of urgency look into ways by which, the need to learn by nurses can be accommodated without compromising the mandate of the organization. The finding may also suggest that more online, night, weekend and sand witch programs be introduced to accommodate the need of the nurses to learn. 65 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION The findings of this study also indicated that participants identified management of health facility as contributing to the challenges they face in pursuing continuing professional education. Participants lamented that information concerning learning programs were not given to them on time to enable them prepare adequately to attend such programs. This sometimes led to participants not being able to attend continuing professional education activities. They also claimed that the information on continuing professional education was sometimes not given to them at all, only those chosen to attend the programs were notified. The facility may have various reasons for not giving information to nurses on time however, in order to create a culture of learning at the health facility management must reconsider some of its practices as this unfortunate trend is not likely to promote learning at the facility and may account for participants claiming that there was nothing at the workplace that motivated them to learn. Nurse Managers can encourage learning by ensuring that information is disseminated early enough for nurses to adequately prepare for workshops or conferences. Shortage of staff also accounted for participants not being able to take part in continuing professional education activities, nurses were unable to leave their work place to attend workshops and conferences because there may be no replacement for them (Feldacker et al., 2018). The findings of the study revealed that quota of ten nurses were selected to be granted study leave every year by the Ghana Health service. This could be due to insufficient number of nurses at post. However, issues of staff shortage should be addressed by the Ghana Health Service and the Health facility in order to ensure nurses are motivated to learn. Unfair selection process by management of the facility was identified by participants as another barrier. Participants in the study stated that selection for 66 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION continuing professional education activities was bias, favorites were always chosen by the nursing administration. This view held by nurses is likely to have a negative effect on participating in learning activities. Choosing of favorites by nurse managers can also mean that some nurses who are not favorites will never be chosen to attend learning programs and this eventually have a negative effect on patient care. On the other hand, those who are always chosen may get the opportunity to participate in several continuing professional education programs but may still not have their particular learning needs met as learning is not by plan but only because she or he has been chosen to attend. 5.4 Strategies to Enhance Continuing Professional Education Participation Participants suggested several strategies that will enhance their participation in continuing professional education. Participants suggested that embargoes on study leave be removed, so that facilities that can release their staff to pursue continuing profession education because they have enough staff do so. Although Ghana Health service has a policy that nurses can obtain study leave after five (5) years, several nurses do not get the opportunity even after serving for five years and this trend appears to have created a lot of frustration and distrust of the employer among the nurses. It is necessary therefore that Ghana Health service reviews its’ policy on study leave. The employer should work on other avenues that will enable their staff to participate in continuing professional education, especially when study leave cannot be grated but the nurse is due. Participants in this study suggested that more nurses should be employed to mitigate the barrier of shortage of staff. This suggestion implies that participants when more nurses are employed into the service more nurses will get the opportunity to 67 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION successfully participate in continuing professional education. The Ghana Health Service and the Health Facility should also device strategies in the meantime, to address staff shortage so that nurses’ are not deprived of learning opportunities. As studies have shown participating in continuing professional education reduces attrition of nurses (Ispir & Duygulu, 2017). Participants also suggested that for workshops organized at the health facility external facilitators be brought to teach the topics and workshops should be organized every quarter for nurses. Participants further suggested that for workshops organized by the Ghana Health Service the nursing administration should allow the nurses to choose the workshops they had interest in. workshops organized by the Ghana health service are very important to the professional development of health personnel, however, according to theories on education interest in a learning programs facilitates the learning process. Nurses should therefore be sent to workshops that they have interest in. The interest of a nurse should be sought before sending the nurse for a workshop. To ensure adequate participation in continuing professional education all stakeholders must be involved to devise appropriate strategies that will enhance learning among nurses (Clark et al. 2015). Participants further suggested that the nursing administration should ensure that every nurse gets the opportunity to participate in informal continuing professional education by proper keeping records of those who have been for workshops and those who have not. This will ensure that every nurse gets the opportunity to participate in continuing professional education. The issue of favoritism should be addressed by the health facility and nursing administration because when nurses engage in continuing professional education it leads to nurses providing better care for patients (Hegney et 68 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION al. 2010; Nsemo et al., 2013; Richards & Studies, 2010). Thus, opportunities should not only be given to favorites but should be made available to all nurses. Participants also suggested that information concerning continuing professional education should be disseminated to the nurses on time to allow them to adequately prepare. The nursing administration should correct the unfortunate practice of withholding information concerning workshops till the last minute. Bureaucratic practices that slow down the dissemination of information should be reconsidered to ensure a culture of learning (Clark et al. 2015). The final suggestion given by participants to enhance their participation in continuing professional education was for financial support to be provided. Several studies have suggested being given paid leave to study enhances participation in continuing professional education (Baurrow et al. 2016; Chong & Sellick, 2011; Ni et al., 2014; Thomas et al., 2015). These studies have shown that when employers support nurses financially to learn it enhances participation in continuing professional education programs. 5.5 Summary of Discussion To summarize the discussion of the study, nurses have a positive perception of continuing professional education. They perceived continuing professional education as a means of acquiring knowledge and upgrading as well as a way of exposing themselves to new trends. Nurses were motivated to participate in continuing professional education in order to acquire knowledge and skills, upgrading, to renew professional licence, social networking and higher academic qualification of colleagues. 69 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION Barriers that prevented nurses from participating in continuing professional education were situational barriers such as family responsibilities, inadequate time and high cost of fees. Institutional barriers identified were rigid schedules, poor treatment of adult learners, choice of venue and choice of facilitator. Additional barriers that emerged in the study were organizational and facility barriers. Participants also suggested several strategies to enhance continuing professional education participation. The strategies were review of policy on study leave, health facility strategies, nursing administration strategies and financial support. 70 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION CHAPTER SIX SUMMARY, CONCLUSION AND RECOMMENDATION 6. 0 Introduction This chapter presents the summary of the study, implications of the research findings to nursing practice, and research, limitations of the study, conclusions and recommendations. 6. 1 Summary of the Study Continuing professional education is essential to the life of every professional. Nursing as a profession cannot thrive without it. Therefore, this study explored the experiences of registered nurses with continuing professional education. The qualitative descriptive design was used to explore the experiences of registered nurses with continuing professional education. The study specifically looked at their perceptions, motivation and barriers to continuing professional education. The strategies to promote participation in continuing professional education was also examined. The purposive sampling technique was used to recruit ten professional nurses who have worked for at least three years at the Princess Marie Louise children’s hospital. A semi - structured interview guide with open ended questions based on the objectives of the study and the constructs of the Cross Chain of Response Model was designed to elicit responses from participants. The interview guide was pretested with professional nurses with similar characteristics at the Ledzokuku- Krowor Municipal Assembly (LEKMA) hospital. Permission was sought from the management of the Princess Marie Louise Children’s Hospital to recruit participants from the facility after ethical clearance had been obtained. The researcher was introduced to registered 71 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION nurses who were briefed on the purpose and objectives of the study. Professional nurses who met the inclusion criteria and consented to be part of the study were recruited as participants. An appropriate day, time and place was scheduled with each participant. Interviews were conducted with participants and their permission sought to record the interview session and all major happenings of the day were recorded in a field diary. Each interview session lasted from 30 minutes to 1 hour and data was read severally and transcribed at the end of the session. The interviews got better as data collection continued. Saturation was achieved with the tenth participant when no new information was added to the responses. Data analysis was done alongside data collection. Data were read and re - read to make meaning of the data and codes were identified as well as sub - themes. After the codes and sub - themes with quotations were identified, the transcripts, demographic data, field diary and audio recordings were kept safe electronically with only the researcher and her supervisors who could have access to it. The four main themes that guided the study were the perception of continuing professional education, motivational factors for continuing professional education, barriers to continuing professional education and strategies to enhance continuing professional education participation. In analyzing the data under the theme “perception of continuing professional education”; three sub - themes emerged from the data. The findings from the study suggest that professional nurses have a positive perception about continuing professional education. The nurses perceived engaging in continuing professional education as important to both their professional and personal development. 72 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION The theme “motivation to continuing professional education” had five sub- themes. The sub-themes were acquisition of knowledge and skills, upgrading, renewal of professional licence, social networking and higher academic qualification of colleagues. The theme “barriers to continuing professional education” had three sub - themes emerging from the data, some of the barriers nurses faced were family responsibilities, inadequate time and high cost of fees. Several strategies were also suggested. 6.2 Implications of the Research The outcome of this study has implication for nursing practice, research and education. These have been deliberated upon below. 6.2.1 Implication for Nursing Practice Continuing professional education should be viewed as a tool for building the professional competencies of professional nurses to enable them meet the diverse health needs of their clients. Hence, much attention should be focused on ensuring that, every professional nurse engages in both types of continuing professional education. Nurses should be allowed to pursue formal continuing professional education after serving for five years as stipulated by the Ghana Health Service Human Resource training policy. 6.2.2 Implication for Nursing Education Continuing professional education is necessary for the growth of the professional nurse, therefore right from the beginning of the training of the nurse, the concept of continuing professional education should be introduced to the student nurse. The nursing and Midwifery Council for Ghana, Ghana Health service, 73 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION educational institutions and organizers of continuing professional education should map out appropriate strategies that will help nurses in their pursuit of continuing professional education. Needs assessments should be done before planning of education programs are done, to ensure educational programs are tailored to the needs of the nurse who are the consumers. Facilities should also create environments that encourage and support learning of nurses. 6.2.3 Implication for Nursing Research Further research is needed to find out the strategies that can be used to enhance informal continuing professional education for nurses. Additional research is also needed to explore the perception of nurse mangers concerning continuing professional education and how nurse managers can help to encourage a culture of learning at health facilities. Research is needed to find out the impact of continuing professional education on nursing practice. 6.3 Limitations of the Study The first limitation is the absence of male participants in the study and Older nurses’ who chose not to participate in the study, this may lead to some bias in data collected. Secondly the perception of other stakeholders was not sought, nurse managers, Ghana health service, organizers of continuing professional education programs, this is also likely to create some biases in the findings of the study. 6.4 Insight Gained The study has enlightened the researcher about the research process from identifying a research problem, developing a proposal and the entire process of research writing. The use of a model to guide the research was useful as it helped to 74 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION set objectives for the study, in the review of literature and the discussion of the findings of the study. The researcher has also gained comprehensive knowledge on analyzing and reporting qualitative data. The researcher has also gained extensive insight on the subject that was studied. The researcher finds the experience gained from conducting this study invaluable and a great eye-opener. 6.5 Conclusion of the Study In conclusion, the study employed the qualitative descriptive design in exploring the perception of professional nurses about continuing professional education. Ten study participants which included professional nurses who have completed at least one continuing formal education, taken part in at least two informal continuing professional education and were willing to participate in the study were selected. The study sought to find out the perceptions, motivations and barriers to continuing professional education of professional nurses. Strategies to enhance the continuing professional education of professional nurses was also examined. The Cross Chain of Response Model guided the study. The findings of the study showed that professional nurses have a positive perception about continuing professional education. Notwithstanding the barriers encountered personally by the nurses and at the workplace, the study revealed that professional nurses are keen on participating in continuing professional education. From the findings of the study it is necessary that the Nursing and Midwifery Council for Ghana, Ghana Health service, organizers of continuing professional education for nurses address some of the issues raised in other to enhance continuing professional education for professional nurses. 75 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 6.6 Recommendations of the Study The following recommendations are made based on the findings of the study: 1. All bodies responsible for organizing continuing professional education for professional nurses should do a thorough needs assessment before designing appropriate programs that will promote continuing professional education for nurses. 2. Health facilities should create environments at the work place that promote learning by supporting and encouraging nurses to participate in continuing professional education. 3. Continuing professional education should be included in the basic training of the student nurse, so as to sensitize student nurses about the need to continue learning after basic training. 4. Ghana health service should review its’ police on study leave to ensure every nurse gets appropriate opportunities to participate in continuing professional education. 5. Management of health facilities should plan staff development pathways with nurses to ensure that professional nurses working in their facilities are not deprived. 6. 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What does Continuing professional education mean to you? - How does partaking in continuing professional education impact on nursing practice? Motivation to participate in CPE 1. What are the factors that encourage you to partake in continuing professional education? - What are the personal factors that motivate you? - What are the factors in your work place that motivate you to partake in CPE? 2. What are the benefits to partaking in continuing professional education? Barriers and opportunities to CPE 1. What are the barriers that have prevent you from participating in continuing professional education? - What barriers have you faced personally? - What barriers have you faced at the work place? 2. How do you get to participate in CPE of your choice? Strategies that can enhance CPE delivery 1. How can CPE activities be modified to enhance your assess to CPE? - What is your preferred mode for CPE delivery? 87 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 88 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 89 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 90 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 91 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 92 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 93 University of Ghana http://ugspace.ug.edu.gh CONTINUING PROFESSIONAL EDUCATION 94